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t:.A.\^\2.-:^

^Harvard Uniwcreity

Ch€ COeilical School

■nd

Ch€ School of 'Public Ttealth

GhcGlftof

Dr. Francis W. Palfrey.

1 '

tViE BOSTON
JOUBSiUiU

PRESS NOTICES OF DR. SAVILLS
SYSTEM OF CLINICAL MEDICINE.

" The method of the hook is strikiogly Dovel. The author approaches the various
diseases from the point of view of symptoms and physical signs. ... If there is a royal
road to clinical diagnosis, we find it here. Certainly the path of the medical man who
refers to this book will be greatly smoothed. . . . We have tested the book on several
occasions, and never once found it lacking. ... No one who uses this as a work of
reference wiU be disappointed in it, for the writer has practically included everything
essential for the diagnosis of disease at the bedside. We know of no other work on
clinical diagnosis which so fuUy supplies the needs of the general practitioner as this
one does. " — Medical Timet.

" The second edition shows in every way an advance upon the first, which itself stood
as the wonderful aooompUshment of a Uborious task on pioneer lines." — St. Mary'e
HoepiUU Gazette,

"We have carefully renewed our acquaintance with this manual, and in our opinion
it is the best work on the subject of clinical medicine in the English language. It will
well repay careful atudy."—W*tt London Medical JowmaL

" The fruit of a wide experience, presented in a manner calculated to be of very prac-
tical value to the senior student, and no less to the practitioner of medicine. It departs
from the usual methods of medical textbooks, and deals with the various diseases from the
I)oint of view of their leading symptoms. Differential diagnosis then becomes the prom«
Inent feature, and by careful classification, and an extensive system of cross-references, it
is exceedingly easy to follow out any line of investigation in coming to a diagnosis. But,
while this is the case, room is also found for etiology, pathology, and treatment, so that
complete clinical pictures are presented. The writer is concise in his descriptions. The
book is well illustrated ahd has been brought thoroughly up-to-date. It ought to be
widely known, and should be in the hands of every medical practitioner."— &to«^to
Medical Journal.

"To Dr. Savill occurred the original, and, as he admits, the ambitious, idea of
writing a textbook of medicine which should be clinical in its method, so as to enable
the cardinal symptoms presented by the patient to be referred to their true cause— in
other words, of following the method which must of necessity be adopted in practice,
working from effects back to cause. ... In our review of the first edition wo referred
totheadmirablemannerin which Dr. Savill had carried out his idea, . . . and we wished
the book the success it deserved. . . . The essential feature of Dr. Savill's book is its
practical character. It aims at teaching a practical method of diagnosis, and the direc-
tions given in regard to all diagnostic procedures are thorough, and often comprise
useful hints. We can again confidently recommend Dr. Savill's book as a helpful and
practical work on clinical diagnosis."— lancet.

A SYSTEM

CLINICAL MEDICINE

DEALING WITH THE

DIAGNOSIS, FROG NO SIS, AND TREATMENT

OF DISEASE

FOR

STUDENTS AND PRACTITIONERS

THOMAS DIXON SAVILL, M.D. Lend.

Third Edition
thoroughly revised

NEW YORK

WILLIAM WOOD & COMPANY

MDCCCCXII

HARVARD UNIVERSITY'
SCHOOL OF medicine; A>,'D F'JZLin HLr^-'

■f ilULlM2

PREFACE TO THE THIRD "EDITION

The kind letters received from practitioners at home and abroad, together
with the fact that the second edition of " Clinical Medicine " was sold
out in less than two years, seem to prove that the book is supplying the
want described by Dr. Savill in the Introductory Chapter.

The arrangement and the scheme of the book have been in no way
altered. This edition has been carefully revised, and much new matter
has been added, although the size of the volume remains unaltered. The
additional matters are described very briefly under the symptoms for which
the patient seeks advice, so that they may be dififerentiated from the
other conditions which give rise to the same symptom. Amongst the
cidditions may be named Acute Pulmonary (Edema, Family Congenital
Chotemia, Aplastic Anaemia, Hirschsprung's Disease, the Serum Disease,
Multiple Myeloma and other rare bone diseases, Adrenal itis. Rocky
Mountain Fever, Japanese River Fever, Rat- bite Fever, Psittacosis,
Ochronosis, Enterogenous Cyanosis, Amyotonia Congenita, Family
Periodic Paralysis, Atrophic Spinal Paralysis of Infants, and other rare
conditions which do not merit mention in the preface. Certain sections
have been rewritten.

I have felt very keenly the responsibility of bringing this edition up-to-
date in a manner that would accord with the ideal of its author. To
secure that thorough and adequate revision necessary to render the book
as trustworthy and complete as in previous years I have sought the
assistance of experts in several departments. I desire to express my
gratitude to Dr. F. Foord Caiger, who is responsible for the revision of the
first two groups in the Chapter on Fevers ; to Dr. F. M. Sandwith, for
revision of Tropical Fevers ; to Dr. Leonard WiQiams, for revision of
Diseases of the Thyroid ; to Dr. Angus McGillivray, for revision of the
section on Diseases of the Eyes ; to Dr. Elizabeth Fraser, for revision of
the sections on Immimity and Bacteriology ; and to Dr. R. H. Cole, for
revision of the section on Insanity. I have also to thank those who helped
me with useful suggestions — in Diseases of the Nervous System, Dr. Harry
Campbell ; in Diseases of Women, Dr. L. Garrett Anderson ; and for
valuable advice as to additions throughout. Dr. Frederick Langmead.
To Dr. James Mackenzie I am indebted for two illustrations of polygraph
tracings in Diseases of the Heart, and for advice as to alterations in the
section on the Pulse.

In conclusion, I have gratefully to acknowledge the valuable assistance
throughout, both in the revision and in proof-reading, of Dr. Gordon R.
Ward, who is responsible also for the alterations in the chapter on
Diseases of the Blood.

AGNES SAVILL.

Harley Street,

Jfay, 1912.

Vll

PREFACE TO THE SECOND EDITION

This work differs from current books on medicine chiefly in this respect,
that it approaches the subject from the point of view of symptoma-
tology, first describing the symptoms or effects of disease, and then tracing
these symptoms to their causes — namely, the various diseases which may
be in operation It was written to aid my professional brethren in general
practice in their daily work (which consists of tracing symptoms to their
causal disease) and to help senior students who had reached the stage
when medicine may be profitably studied in the wards. It was an original,
and perhaps a too ambitious, project, but the rapid sale of the first edition,
which has now been out of print neariy two years, and the number of kind
and suggestive letters received from medical men in general practice in
many different parts of the world, and from teachers and senior students,
encourage me to believe that I have in some measure succeeded.

This edition appears in one volume instead of two, as being more con-
venient. The amount of material remains approximatoly the same, new
mattor replacing old. In deference to the wishes of many of my readers,
the smallest of the three types (nonpareil) in the first edition has been
replaced by medium-sized type (brevier), so that now only two main types
instead of three are used. Space has been saved by the lines of type being
closer, and consequently the bulk of the volume forming the second edition
is somewhat smaller than the bulk of the two volumes together which
formed the first.

The arrangement and scope of the work are unchanged. Clinical
medicine moves less rapidly than pathology, so it has not been necessary
to make any very extonsive alterations. The book has, however, been
brought thoroughly up-to-date. The exigencies of a busy life have pre-
vented my giving as much time to its revision as could be wished, but I
have been fortimato in securing the valuable aid of Dr. Frederick S.
Langmead and Dr. Agnes F. SaviU. The last-named is mainly responsible
for the chapter on Diseases of the Skin, the first-named for the alterations
in the chapter on Diseases of the Joints ; both are responsible, with me,
for general revision throughout.

I should like to take this opportunity of acknowledging the valuable
criticisms I have received from many correspondents, and to say that
further suggestions and criticisms from future readers will be gladlv
welcomed.

T. D. S.

September J 1909.

• • ■

via

TABLE OF CONTENTS

INTRODUCrriON

PAOK

Evolution of medioine — Origin of the work — Plan of the work — Special features

— Advantages of the author's method — Responsibilities - - - xx>

CHAPTER I

CLINICAL METHODS

Definitions — CSase-taking ; remarks on the interrogation of. and physioal examina-
tion of patients ; scheme of case-taking — Examination of children and
infants — ^Three methods of diagnosis discussed — Principles of prognosis and
of treatment — General rules in clinical investigation — Classification of
diseases --.-..--- 1

CHAPTER II

THE FACIES, OR EXTER17AL APPEARAKCES OF DISEASE

The physiognomy in various diseases, acute and chronic ; causes of swelling of
the face ; causes of alterations in the colour and complexion of the face ; the
face in detail — The physiognomy in infancy and childhood — Variations in
the form of the skull — The physiognomy in diseases of the nervous system —
The decubitus and attitude in disease — ^The general conformation of the
body — Causes of emaciation — Causes of enlargement of the body ; obesity
- Dwarfism and its various causes - . • - - 15

CHAPTER III

THE HEART AKD PERICARDIUM

Introduction — Part A. Symptomatology : breathlessness ; Cheyne-Stokes res-
piration ; dropsy ; palpitation ; pain in the chest ; syncope ; cough ; cyanosis
— ErythrsBmia ; sulph-hsBmoglobinsemia ; methsemoglobinsemia — Sallow-
ness ; pyrexia ; sudden death — Lymphatism - - - - - 28

Part B. Physical examinaiion : landmarks of the chest ; inspection ; palpation ;
localisation of the apex ; percussion ; resistance to palpation ; auscultation ;
the pulse ; the polygraph and electro-cardiogram - - - - 40

Part C. Diseases of ike heart and pericardium, their diagnosis, prognosis, and
treatment : classification ; routine procedure — Acute diseases : acute peri-
carditis ; acute endocarditis ; ulcerative or malignant endocarditis ; paroxys- i
mal tachycardia ; angina pectoris — Chronic diseases : classification ;
hypertrophy of the heart ; dilatation of the heart ; hydro-pericardium ;
congenital heart disease ; chronic endocarditis, cardiac valvular disease
(C.V.D.) ; varieties of cardiac murmurs ; table of differentiation of various

TABLE OF CONTENTS

PAor

forms of oaidiao valvular disease — Systolic murmurs : mitral regui^tation ;
aortic stenosis ; aortic aneur3r8m ; tricuspid regurgitation ; pulmonary
stenosis ; fallacies in the diagnosis of S3rstolio murmurs — Diastolic murmurs :
aortic reguigitation ; mitral stenosis ; aortic aneurysm ; tricuspid stenosis ;
pulmonary regurgitations ; fallacies in the diagnosis of diastolic murmurs —
Double murmurs : audible at the base ; and at the apex ; fallacies in the
diagnosis of double murmurs — General symptoms of cardiac valvular
disease ; causes of C.V.D. : auricular fibrillation ; prognosis and treatment
of C.V.D.— Fatty heart ....... 50

CHAPTER IV

ANEITRYSM OP THE AORTA AND OTHER INTRATHORACIC TUMOURS

Anatomy of the mediastinum — Intrathoracic aneurysm ; symptoms and signs ;
three clinical and anatomical varieties ; causes ; diagnosis ; prognosis : and
treatment .-.--.... 90

Other mediastinal tumours ; signs and symptoms ; causes and anatomical

varieties ; prognosis and treatment - - - - - - 95

CHAPTER V

THE PULSE AND ARTERIES

The meaning of " the pulse '* — Clinical investigation — Rapid pulse — Slow
pulse : — Stokes- Adams disease — Irregular pulse — High blood-pressure ;
its symptoms, causes, prognosis, and treatment — Low blood -pressure ; its
symptoms, causes, prognosis, and treatment — The pulse in relation to the
prognosis and treatment of disease - - - - - - 98

Diseases of the arteries ; symptomatology ; physical signs and clinical varieties —
Atheroma — Arterial sclerosis — Arterial hjrpermyotrophy — Functional
diseases of the arteries - - - - - - - 11(>

CHAPTER VI

THE LUNGS AND PLEURA

Introduction — Part A. Symptomatology: cough; broathlessness ; pain in the

chest ; hemoptysis ; pulmonary embolism - - - - - 1 1 8

Part B. Physical Examination : inspection and mensuration ; radiography ;
palpation ; percussion : auscultation : ausoulto-percussion : fallacies ; exami-
nation of the sputum - . . 1 2H

Part C. Diseases of the lungs and pleura, their diagnosis, prognosis, and treat-
ment : classification ; routine procedure — Diagnostic table of acute diseases
— Acute diseases without dulness on percussion : acute bronchitis ; acute
suffocative catarrh ; dry pleurisy ; acute pulmonary tuberculosis ; whooping
cough ; acute pulmonary oedemei — Acute diseases with dulness on per-
cussion : acute pleurisy with effusion ; empyema ; acute lobar pneumonia ;
pneumonic form of acute tuberculosis ; aberrant acute pneumonias ; acute
lobular pneumonia — ^Acute disease with hyper-resonance on percussion :
pneumothorax — Paroxysmal disease : asthma — Chronic diseases : classifica-
tion and routine method of procedure — Chronic diseases without dulness :
chronic bronchitis ; plastic bronchitis — Chronic diseases with dulness :
pulmonary tuberculosis ; fibroid phthisis ; hydrothorax ; oedema of the lung
—Rarer diseases : chronic interstitial pneumonia ; thickened pleura ;
malignant disease of the lung ; hydatid cyst ; atelectasis ; syphilis of the lung
— Chronic diseases with hyper-resonance : emphysema, and others —
Diseases with characteristic sputum : bronchiectasis ; gangrene of the lung ;
abscess of the lung : actinomycosis ; aspergillosis ; blastomycosis - - 133

TABLE OF CONTENTS xi

CHAPTER VII

THE 1TPPSB BBSPIBATOBY PASSAQBS AND THE THTBOID GLAND

PAOK

Introduction — ^The Throat : Part A. Symptomatology : sore throat ; hoarse-
ness ------..- 178

Part B. Clinical investigation ....... 179

Pkkrt C. Diseases of the throat : classification of diseases ; acnte catarrhal phaiyn-
gitis ; hospital sore throat ; chronic catarrhal pharyngitis ; granular (follic-
ular) phar3mgiti8 ; granular (adenoid) pharyngitis ; acute parenchymatous
ton^llitis ; acute follicular tonsillitis ; Vincent's Angina ; chronic tonsillitis ;
Bcaiiet fever ; diphtheria ; syphilitic sore throat ; retropharyngeal abscess ;
phlegmonous sore throat ; carcinoma ; tubercle ; acute specific fevers - 180

The larynx : symptoms and cb'nical investigation — Classification of diseases —
Laryngitis ; acute laryngitis ; oedema glottidis ; the swallowing of a foreign
body ; chronic laryngitis ; perichondritis ; chronic infantile stridor ; chronic
tuberculous laryngitis ; chronic syphilitic larjmgitis ; new growths, benign
and malignant ; paralysis of the vocal cords ; laryngismus stridulus - - 188

TAe nasal cavities : symptoms and physical examination — Classification of
diseases — Acute nasal discharge (rhinorrhosa) : acute rhinitis ; snuffles ;
diphtheria ; acute coryza ; hay fever ; glanders ; myiasis — Chronic inoffen-
sive discharge : chronic rhinitis, simple and hypertrophic ; cerebro-spinal
rhinorrhosa ; ulcerations, polypi, and sinus disease ; post-nasal catarrh —
Chronic offensive discharge (ozena), its causes, prognosis, and treatment —
Nasal obstruction, snoring, and mouth breathing ; its causes, prognosis, and
treatment — Epistaxis - - - - - - - 199

The thyroid gland — Introduction — Symptomatology — Physical examination and

classification of diseases — Graves' disease ; bronchocele ; cretinism - - 209

CHAPTER VIII

THE MOUTH, TONaUE, AND QXTLLBT

The mouth — ^Introduction — ^The lips ; the breath ; the saliva ; the palate ; the

teeth ; toothache ; the gums ; pyorrhoea alveolaris ; stomatitis • • 210

The tongue : furring of the tongue ; ulcers of the tongue ; white patches ; acute
swelling of the tongue ; chronic swelling ; hypertrophy and atrophy of the
tongue ; warts, fissures, and cicatrices ..... 222

The (ri</2e<— Symptomatology — Ph3rsical examination — Causes of dysphagia :
tumour ; malignant disease ; simple or non-malignant stricture ; spasm of
the pharynx or oesophagus ; foreign bodies ; acute oesophagitis ; simple
ulcer ; paralysis of the g^et ; dilatation or diverticulum of the gullet ;
prognosis and treatment of dysphagia ..... 226

CHAPTER IX

THE ABDOMEN

Introduction — Part A. Symptomatology : local symptoms ; fallacies in the

diagnosis of acute abdominal pain ; general symptoms - . - 233

Pftrt B. Physical examination : inspection ; palpation ; percussion ; mensura-
tion ; fallacies in the diagnosis of abdominal enlargement ... 235

Pftrt C Abdominal disorders, their diagnosis, prognosis, and treatment : routine
procedure and classification — Causes of acute abdominal pain, with collapse :
rupture of a cyst or organ, or perforation of the alimentary canal ; acute
peritonitis ; rarer causes — Acute abdominal pain, without collapse ; colic ;
rarer causes — Chronic abdominal pain : appendicitis ; chronic peritonitis ;
movable kidney ; intestinal dyspepsia and intestinal catarrh ; enteroptosis ;
incipient or obscure visceral or spinal disease ; diseases of the pancreas • 238

xii TABLE OF CONTENTS

PAGK

Oeneralised abdominal enlargement: classifioation — Routine prooedare — ^Tym-
panites ; gas in the peritoneum ; fluid in the abdominal cavity ; physical signs
of fluid ; signs of ascites — Causes of ascites : portal obstruction ; cardiac
disease ; kidney disease ; chronic peritonitis ; anaemia — ^Treatment of ascites
— Clauses of encysted fluid in the abdomen : ovarian cyst ; rarer cysts - • 255

Abdominal tumours — Method of procedure — ^Tumours special to the various

regions of the abdomen ....... 262

FlaUening or recession of the abdomen ...... 268

CHAPTER X

THE STOMACH

Introduction — Part A. Symptomatology : gastric pain ; nausea or vomiting :
Cyclical or recurrent vomiting ; hsematemesis ; other local symptoms ;
general or remote symptoms ...... 269

Part B. Physical examination : inspection ; palpation ; percussion ; motor
insufficiency of the stomach ; bismuth meal ; examination of stomach
contents ......... 279

Part C. Diseases of (he stomach, their differentiation, prognosis, and trecUment :
routine investigation and classification — Acute disorders : acute dyspepsia ;
acute or subacute gastritis — Chronic disorders ; chronic djrspepsia (atonic
and acid) ; gastralgia ; simple ulcer ; cancer of the stomach ; chronic
gastritis ; dilatation of the stomach or gastric atony ; neurasthenic dys-
pepsia ; gastroptosis ....... 285

Dietaries and invalid foods — Artificial feeding of infants • - - 301

CHAPTER XI

THE INTESTINAL CANAL

Introduction — Part A. Symptomatology : diarrhoea ; constipation ; abdominal

pain ; remote or general symptoms ...... 306

Part B. Physical examination : examination of the abdomen ; examination of

the stools ; various intestinal and other parasites .... 307

Part C. Diseases of the intestinal canal, their diagnosis, prognosis, and treatment :
routine procedure ; classification of diseases — Causes of acute diarrhoea —
Dysentery — Cholera — Causes of chronic diarrhoea — Psilosis or sprue —
Tenesmus — Blood in the stools — Haemorrhoids — Intestinal worms — Con-
stipation— Acute intestinal obstruction — Chronic intestinal obstruction • 314

CHAPTER XII

THE LIVER AND SPLEEN

Introduction — Part A. Symptomatology : pain and tenderness over the liver ;

jaundice ; icterus neonatorum ...... 339

Part B. Physical examination : inspection ; palpation ; percussion ; fluid in the

peritoneum - ........ 343

Part C. Diseases of the liver: routine procedure and classification — Acute
diseases : acute congestion of the liver ; catarrhal jaundice ; epidemic jaun-
dice ; gall-stones and biliaiy colic ; diseases of the gall-bladder ; perihepa-
titis ; abscess of the liver ; subphrenic abscess ; actinomycosis of the liver ;
acute yellow atrophy — Chronic diseases : routine procedure and classifica-
tion— Diseases in which the liver is normal or diminished in size : functional
derangement of the liver ; atrophic cirrhosis of the liver — Diseases in which
the liver is enlarged and painless : hypertrophic cirrhosis of the liver ; fatty
liver ; lardaceous liver ; hydatid tumour of the liver — Diseases in which the

TABLE OF CONTENTS xiii

PAGE

liver is enlarged and painful : ohronio oongestion ; cancer ; abscess — Rare

tumours — Floating liver ....... 346

The spleen — Introduction — Part A. Symptamatoloffy - - . - 370

Fart B. Physical examination : palpation ; percussion ; surface landmarks ;

diagnosis of enlargement - - - - • - - 371

Part C. Diseases of the spleen : Causes of acute and chronic enlaigement —

Irregular spleen — Wandering spleen — Atrophy of the spleen - - 373

CHAPTER XIII

THB UBINB

Introduction — Part A. Symptomatology : alterations in the urine ; pallor of the
surface and malaise ; renal dropsy ; general symptoms ; complications and
secondaiy inflammations ; pain in the kidney ; ursBmia - • - 378

Part B. Physical examination of the urine : a. Physical characers of the urine :
appearance ; reaction ; specific gravity ; odour ; the diurnal quantity —
h. Chemical examination of the urine : albumen ; nudeo-albumen ; mucin ;
sugar ; urea ; uric (i.e., lithic) acid ; bile ; blood ; pus ; salts in the urine ;
proteids in the urine ; other rare constituents — c. The urinaiy deposit :
cloudiness of the urine ; microscopic specimens ; organised constituents ;
ciystalline and inorganic deposits ...... 383

Physical examination of Qie kidneys : landmarks ; palpation ; percussion ; other

methods of examination - - - • • - '401

Part C. Urinary disorders, their diagnosis, prognosis, and treatment: routine
procedure — Classification — Albuminuria : acute nephritis ; chronic tubal
nephritis ; chronic interstitial nephritis ; amyloid kidney ; renal congestion
and its various causes — Hssmaturia, its forms and causes : renal calculus
and renal colic ; injuiy of the kidney ; paroxysmal hemoglobinuria — Pyuria,
its forms and causes : urethritis ; cystitis ; pyelitis — Altered specific gravity :
caiises of diminution and increase of specific gravity ; polyuria ; diminished
quantity of urine — Glycosuria ; temporary ^ycosuria ; diabetes mellitus ;
diabetes insipidus — Retention of urine — Suppression of urine — Incontin-
ence of urine : true incontinence ; increased frequency of micturition ;
nocturnal incontinence — Cloudiness of the urine, and its causes — Renal
tumours : hydronephrosis ; pyonephrosis ; perinephric abscess ; malignant
disease ; cystic disease ; hyatid ...... 402

CHAPTER XIV

DISEASES PEOULIAB TO WOMEN

Introduction — ^Part A. Symptomatology : list of local symptoms ; list of general

symptoms — Case-taking ....... 435

Part B. Physical examination : external examination ; vulvo-vaginal examina-
tion ; bimanual examination ; instruments to aid examination - - 436

Part C. Diseases of women, their diagnosis, prognosis, and treatment : routine
procedure and classification of diseases — Diseases of the vidva ; leucorrhosa,
of vaginal origin and of uterine origin ; dysmenorrhoea, spasmodic, in-
flammatory, membranous ; monorrhagia and metrorrhagia ; uterine fibroid ;
subinvolution ; the menopause ; maLgnant disease of the uterus ; extra-
uterine pregnancy ; treatment of hsomorrhage — ^Amenorrhcoa : pregnancy
— Pelvic pain : perimetritis (pelvic peritonitis) ; parametritis (pelvic cellu-
litis) ; inflammation of the uterine appendages ; pelvic hsematocele ; uterine
flexions and versions — Pelvic tumours and vaginal swellings : prolapse of the
vaginal walls ; prolapse of the uterus ; inversion of the uterus — Disordered
micturition ; painful defaecation ; painful sitting ; dyspareunia — Backache • 438

xiv TABLE OF CONTENTS

CHAPTER XV

PYREXIA. MIGBOBIO DISEASES

PACK

Introduction — Definitions : acute specific fever ; infection ; contagion ; clinical

characteristics of microbic diseases ; epidemic ; sporadic ; endemic - • 459

Part A. SymptoffuUology : symptoms attending pyrexia ; incubation and other

stages of acute specific fevers ; rigors ; delirium ; the typhoid state - • 460

Part B. Physical examiruUion : clinical thermometry ; the temperature chart ;
types of pyrexia ; subnormal temperature ; examination of organs ; ex-
amination of blood ........ 468

Part C. The diagnosis, prognosis, and treatment of microbic disorders : routine
procedure ; classification — Oroup /. Exanthemata or eruptive fevers :
introduction ; varicella or chicken-pox ; scarlet fever ; erysipelas ; small-
pox ; vaccinia ; measles ; rotheln ; dengue ; typhus ; anthrax ; glanders —
Oroup II. Continued pyrexia : list of fevers of a continued type ; enteric
or typhoid fever ; diphtheria ; influenza ; rheumatic fever, pneumonia, and
other inflammatory disorders ; whooping cough ; mumps ; glandular fever ;
plague ; undulant fever ; yellow fever ; epidemic cerebro-spinal meningitis ;
relapsing or famine fever ; thermic fever or heat-stroke ; kala-azar ;
phlebotomous fever ; rat-bite fever ; Japanese river fever ; psittacosis —
Oroup III. Intermitting pyrexia : list of fevers of an intermittent type ;
ague ; remittent fever ; " blackwater " fever ; latent tuberculosis ; acute
general tuberculosis ; visceral syphilis ; acute pysBinia or septicsemia ; sub-
acute and chronic septic conditions (e.g., abscess, ulceration, etc.) ; the rarer
causes of intermitting pyrexia ; trypanosomiasis - - - - 471

General treatment of microbic disorders : immunity ; vaccine therapy ; remedial
immunisation ; notification and isolation ; disinfection and prevention ; diet ;
hyperpyrexia -.----.. 629

CHAPTER XVI

GENERAL DEBILITT, PALLOR, AND EMACIATION

Introduction — Part A. Stfmptomatology : general debility ; pallor of the skin ;

emaciation ......... 543

Part B. Physical examination : examination of the viscera ; observations on the

weight and the temperature ; examination of the blood ... 545

Part C. Diseases which give rise to general debility, toOh or wOhout ancsmia and
emacicUion, iheir diagnosis, prognosis, and treatment : routine procedure ;
classification — Ancsmic disorders : chlorosis ; pernicious ansemia ; congenital
anaemia ; syphilis ; plumbism ; latent tuberculosis or carcinoma ; chronic
visceral disease ; haemorrhage and other causes of long continued drain ; J
leukaemia ; chloroma ; Hodgkin^s disease ; splenic anaemia ; scurvy ; haemo-
philia ; tropical diseases and parasites ; anaemias of childhood — Emaciation ;J
malignant disease ; defective feeding and digestive disorders ; tuberculosis ; ]
diseases of the pancreas and of the nervous sjrstem ; marasmus in childhood
— Debility only : senile decay and arterial disease ; nephritis ; functional
nervous diseases ; djrspepsia ; obscure abdominal or chest disease ; myx-
oedema ; Addison's disease ....... 558

CHAPTER XVII

THE EXTREMITIES

Introduction — Part A. Symptomatology : Pain in the limbs - - 699

Part B. Physical examination : inspection of the limbs ; varicose veins ; oedema ;

glandular swelling ; other local and constitutional signs - - - 601

TABLE OF CONTENTS xv

PAOB

Part C. Diagnosis, prognosis, and treatment of diseases causing symptoms refer-
(iNe to the extremities : routine prooeduie ; classification — Alterations in
colour or contour of the extremities : erythromelalgia ; gangrene ; Raynaud's
disease ; dead hands ; intermittent claudication — Diseases of the joints :
acute gout ; acute rheumatism ; acute gonorrhodal arthritis ; acute rheuma-
toid arthritis ; pysBmia and other constitutional conditions ; traumatism and
extension from adjacent bone ; chronic gout ; chronic riieumatism ; rheuma-
toid arthritis ; osteo-arthritis ; spondylitis deformans ; gonorrhoea! arthritis ;
septic processes ; tuberculosis ; syphilis ; hysterical and neuropathic joint
disorders — Diseases of the muscles : rheumatism ; new growths ; trichinosis ;
myositis — Diseases of the bones : acute osteomyelitis ; rickets ; chronic oste-
itis and periostitis ; tumours ; acromegaly ; achondroplasia ; pulmonary
osteo -arthropathy ; osteitis deformans ; mollities ossium ; leontiasis ossea and
other rare diseases - ,.•••.. 605

CHAPTER XVIII

THE SKIN

Introduction — Part A. Symptomatology : pruritus .... 639

Part B. Physical examination : necessary apparatus ; inspection ; palpation ;

symmetry ; subjective sensations ; history ; etiology - - . 640

Part G. Diagnosis, prognosis, and treatment of skin diseases : routine procedure ;
classification — Group I. Dry Eruptions : wheals ; urticaria — macules or
erythema ; serum disease ; roseola ; drug eruptions ; erythema multiforme ;
rosacea ; lupus erythematosus ; erythema nodosum and other localised ery-
themas— ^papules : acne ; prurigo ; scabies ; syphilis ; lichen planus ; keratosis
pilaris ; milium ; lichen scrofulosorum ; adenoma sebaceum — scales ;
psoriasis ; seborriioBio dermatitis ; syphilis ; exfoliative dermatitis ; pityriasis
rosea ; pityriasis rubra pilaris ; ichthyosis ; erythrasma — Oroup II,
Vesicular Eruptions : eczema ; herpes ; varicella ; sudamina ; hydrocystoma ;
dermatitis herpetiformis ; pemphigus ; epidermolysis bullosa — Oroup III.
Pustular Eruptions : impetigo ; syphilis ; sycosis ; boil ; carbuncle ; kerion —
Oroup IV, Multiform Eruptions: syphilis; scabies — Oroup F. Nodular
Eruptions : lupus vidgaris ; gumma ; new growths ; leprosy ; Bazin's disease ;
moUuscum contagiosum ; mycosis fungoides ; leukaemia ; Yaws ; sporotri-
chosis ; Madura foot ; blastomycosis— (Troup VI, Ulcers : inflammatory ;
contagious ; neoplastic — Oroup VII, Excrescences : wart ; condyloma ;
com ; papilloma lineare ; keratodermia ; acanthosis nigricans ; angiokera-
toma—-(Traap VIII. Atrophies and Scars : scleroderma ; keloid — Oroup IX,
Pigmentary and Vascular Changes : chloasma ; lentigo ; pityriasis versi-
color ; moles ; purpura ; urticaria piginentosa ; xeroderma pigmentosa ;
xanthoma ; morphoda ; oohronosiB— -Oroup X, The Sweat : anidrosis ;
hyperidrosis ; bromidrosis ; chromidrosis — Oroup XI, Diseases of the
Scalp and Hair : ringworm ; favus ; alopecia ; seborrhosa ; pediculosis ;
canities ; hypertrichosis — Remarks on treatment of skin diseases - - 644

CHAPTER XIX

THE KBBV0U8 SYSTEM

Introduction — Anatomical and pathological preliminaries — Part A. Sympto-
matology : mental and motor defects ; nervousness ; pain and neuralgia ;
headache ; disordered sleep ; vertigo ; subjective sensations ... 692

Part B. Clinical investigation : mental and general symptoms ; pyrexia ;
muscular system ; reflexes ; electrical reactions ; special senses and cranial
nerves ; cutaneous sensation ; organic reflexes ; trophic changes ; vasomotor
and sympathetic systems - - - - - - -711

xvi TABLE OF CONTENTS

PAOB

Part C. Diagnosis, prognosis, and treatment of diseases of the nervous system :
routine prooedure ; olassifioation — Group /. Generalised Neuroses : neuras-
thenia ; hysteria ; hypochondriasis ; alcoholism ; drug habits ; collapse —
Qroup II. Mental Symptoms : sudden and transient unconsciousness and
its causes ; prolonged and complete unconsciousness (coma), and its causes
— Partial mental defects : defects of speech, memory, and attention — acute
perversions of the mind— chronic perversions of the mind : mania ; melan-
cholia ; dementia ; special types of insanity — ^prognosis and treatment of
insanity— hypnotism — mental deficiency in adolescence and in childhood —
Group III, Intraorauial Inflammation : tuberculous meningitis ; acute
meningitis ; posterior basic meningitis ; cerebral abscess ; sinus thrombosis
— Group IV, Motor Disorders : Paralysis : hemiplegia ; cerebral tumour ;
localisation of intracranial lesions ; hemiplegia in children — paraplegia :
compression paraplegia ; spiual localisation ; myelitis ; spinal tumour,,
haemorrhage, and pachymeningitis ; system lesions of the cord ; infantile
cerebral and spinal paralyses ; multiple neuritis ; beri-beri ; functional para-
plegia ; railwa^^ spine ; Caisson disease ; prognosis and treatment of para-
plegia— brachiplegia ; amyotrophic lateral sclerosis — monoplegia; single
nerve paralysis ; plexus paralysis ; spinal, cerebral, and functional mono-
plegia— generalised paralysis ; toxic causes ; myasthenia gravis ; encepha-
Utis ; intracranial, bulbo-spinal, and spinal lesibns ; Liandry*B paralysis —
Inco-ordination and Gait : tabes dorsalis ; spinal pachymeningitis and
tumour ; Friedreich's disease ; ataxic paraplegia ; cerebellar tumour — In-
creased Muscular Action : tonic spasm ; writer's cramp ; cramp ; tetanus
tetany ; hydrophobia ; Thomson's disease — ^tremors and clonic spasms
paralysis agitans ; disseminated sclerosis ; functional, toxsemic, and oi^ganic
tremors ; chorea ; myoclonus multiplex ; habit spasm ; clonic facial spasm
torticollis ; post-paralytic spasms ; prognosis and treatment of tremor and
spasm — convulsions : epilepsy ; hysteria ; intracranial and toxasmio causes
Stokes- Adams disease ; convulsions in infancy and childhood — ^Muscular
Atrophy : acute anterior poliomyelitis ; progressive muscular atrophy
spinal and nerve lesions with amyotrophy ; idiopathic muscular atrophy
arthritic amyotrophy — Group V, Pain and Sensory Symptoms : neuralgia
sciatica ; migraine ; hemiansesthesia ; ansesthesia ; hypersBsthesia ; par-
SQsthesia ; syringomyelia — Group VI, Cranial Nerves and Special Senses
smell ; vision ; defects in the pupils ; oculo-motor defects ; ophthalmoscopic
changes ; sense of taste ; facial paralysis ; hemiatrophy facialis ; deafness
the ^osso-phaiyngeal, vagus, spinal accessory, and hypoglossal nerves
bulbar paralysis — ^The Skxdl : hydrocephalus - - - - 721

CHAPTER XX

EXAMINATION OF PATHOLOGICAL FLUIDS AND CLINIGAL BAOTEBIOLOOY

Methods of obtaining pathological fluids : paracentesis abdominis ; liver and lumbar
puncture — how to examine pathological fluids ; characters of pathological
fluids — Clinical bacteriology : methods and stains ; micro-oi^ganisms found
in the sputum, false membrane, pleural effusion, pus, the stools, the urine,
the blood, the cerebro-spinal fluid — Examination for spirochsete pallida - 896

Formulffi of Useful Prescriptions ...... 908

Index ------ ... 919

LIST OF ILLUSTEATIONS

PLATES IN COLOUR

Plate I. — Small-pox - - - - -To face page 484

Plate II. — ^Measles - - - - .... 488

Plate III. — Blood Films - - - - , ., 562

Plate IV. — Bacteria - - - - ,. „ 902

IN THE TEXT

PIO. PA.r.E

1. Myzcedema ........ 18

2. Exophthalmic GotTBE - - - - - - - 19

3. Hereditary Syphilis • - • -20

4. Attitude op Paralysis Aoitans - - 23

5. PsEUDO -Hypertrophic Paralysis - - 24
6 AND 7. Cretinism - - - - - - 27

8. Cheyne-Stokbs Respiration - - - - - 31

9. Superficial and Deep Bulness op Heart and Liver - - 43
10. Diagram of the Cardiac Cycle - - - - - 45
n. The Heart and Great Vessels in situ - 40
12. Situation of Cardiac Murmurs - - - 47
13 AND 14. Polygraph Tracings - - 49

16. DuLNESS IN A Case of Rheumatic Pericarditis • - 53
19. Chart of a Case of Malignant Endcoarditis - - - - 68

17. Scheme of the Circulation of the Blood - - 73

18. Propagation of Murmur of Aortic Stenosis - - 76

19. ,, „ „ IN Aortic Regurgitation - - 76

20. Various Murmurs met with in Mitral Stenosis - 78

21. Pulse Tracings showing Efficacy of Bleeding - 87

22. Pulse Tracings showing the Efficacy of Massage - - 87

23. Tracheal Tugging -.....-- 93

24. Normal Pulse Tracing ....-.- 100
26. .. „ .. ... -100

26. RiVA-Rocci Sphygmomanometer - - 101

27. High Tension Pulse Tracing ...... 106

28. Pulse Tracing showing Reduction of High Tension - - 108

29. Low Tension Pulse Tracing ...... 109

xvii

XVlll

LIST OF ILLUSTRATIONS

Fia.

30. Tracing of Water-Hammbr Pulse ....

31. The Senile Pulse ---....

32. Abteeial Sclerosis ------.

33. Anterior Thoracic Regions .....

34. Chest op Emphysema ......

36. Rachitic Chest .......

36. Pigeon Breast .......

37. The Lungs and other Viscera prom the Back

38. Elastic Fibres .......

39. Charcot- Leyden Crystals- .....

40. Diagram showing the Production of RAles and Rhonchi

41. Diagram showing Physical Signs op Pleurisy -

42 AND 43. A Case op Pleuritic Effusion - . - .

44. Chart op a Case op Acute Lobar Pneumonia -

46. Diagram op the Physical Signs in Hydbopneumothorax

46. Bronchial Cast .......

47. The Three Stages op Pulmonary Tuberculosis

48. Laryngoscopy .......

49. The Larynx in Quiet Inspiration ....
49a. „ „ IN Forced Inspiration ....
60. „ „ IN Moderate Abduction ....
51. „ „ IN Cadaveric Position ....

52. „ „ DURING PhONATION - ... -

53. ,, „ IN Bilateral Abductor Paralysis

54. „ ,, IN Left Abductor Paralysis

55. „ „ in Total Bilateral Paralysis

56 AND 57. The Larynx in Partial Bilateral Abductor Paralysis
58. Nasal Speculum .......

69. OIldium Albicans --....-

60. Regions op the Abdomen ......

61. Vomited Material .......

62. Microscopical Appearances op the F^bces

63. Head op the Tjbnia Mediocanbllata ....

64. T-BNiA Solium

65. Bothriocephalus Latus

66. OxYURis Vermicularis

67. ascaris lumbriooides

68. Trichocephalus Dispar

69. Ankylostomum Duodenale

70. Area op Liver Dulness -

71. Cholestbrin Crystals

72. Tyrosin, Leucin, and Cystin

73. The Stomach and Duodenum

74. HooKLBTS prom a Hydatid Cyst

75. Urinombter -

76. Carwardinb's Sacoharimeter

77. DOREMUS' Urbameter

78. Renal Tube Casts -

FAGK

109

112

113

124

125

126

128

133

137

141

142

145

150

156

158

179

189

196

195

196

197

200

225

237

282

309

310

311

344

351

352

367

384

388

389

396

LIST OF ILLUSTRATIONS

XIX

FIO.

79. Rbnal Epithelium .....

80. Bladder Epithelial Cells ....

81. Appeabances of Red Blood Corpuscles and Pus Cells in the

82. Urates -....-.

83. Uric Acid Crystals .....

84. Triple Phosphates .....

85. Basic Magnesium Phosphate - -

86. Neittbal Phosphate . . . . .

87. Calcium Oxalate - .....

88. „ Carbonate .....

89. Eoo of Bilharzia Hjcbiatobia ....

90. Chart from a Case of Septic Absorption

91. Types of Pyrexia- .....

92. Chart from a Case of Scarlet Fever -

93. Chart of Unmodified Small-Pox

94. „ FROM A Case of Modified Variola

95. „ ,, ,, of Malignant H-smorrhagic Small-Pox

96. „ ,, ,, OF Measles - - - -

97. „ „ „ OF Enteric Fever -

98. „ „ „ OF Diphtheria

99. Types of Pyrexia in Ague - - - -

100. Types of Mosquito .....

101. Chart from a Case of Acute Miliary Tuberculosis -

Urine -

OF Visceral Syphilis

OF Acute Septicemia

OF Chronic Fymmia

OF Malignant Endocarditis

102. ..

103. „

104. ..

105. „

106. Wright's Capsule- .....

107. Antitoxin Syringe .....

108. The Tetanus Bacillus . . . . -

109. The Typhoid Bacillus .....

110. gowebs' h.smoolobinometer ....

111. Thoma-Zeiss HiSMocYTOMETER ....

112. poikilocytosis ......

113. Parasite of Malaria .....

114. FiLARiA Sanguinis Hominis ....
116. Trypanosoma in Blood of a Rat

116. Blood Spectra ......

117. Spiroch-«tb Pallida (Treponema Pallidum) of Syphili:3

118. A Case of Elephantiasis Telangiectodes

119. A Case of Elephantiasis Lymphangiectodbs -
120 AND 121. A Case of Erythromelalgia -

122. Chart of a Case of Rheumatic Fever -

123. A Case of Rheumatoid Arthritis

124. Trichina Spiralis encysted in Muscle

125. Achondroplasia ......

126 AND 127. Diagrams of the Common Situations of Certain Eruptions
128. A Case of Erythema Iris .....

PAOB

396

397

398

399

400

414

450

469

475

481

482

483

488

494

500

516

518

521

522

524

527

528

534

535

536

537

547

548

551

553

556
557
569
602
603
606
614
622
630
637
643
647

LIST OF 1LLVSTRATI0N8

KIO. PAGE

129. Pedictjlus Corporis ....... 653

130. Pediculus Pubis ---.---- 663

131. acarus scabiei -...---. 654

132. A Case op Tinea Circinata ...... 666

133. Mycelium of Tinea Circinata ...... 667

134. A Case of Verruca Necrogenica ..... 680

135. MiCROSPORON Furfur ....... 684

136. Small Spored Ringworm .---..- 687

137. Large Spored Ringworm - ...... 687

138. achorion schunleinu ....... 688

139. Pediculus Capitis ....... 690

140. Nits of Pediculus Capitis ...... 690

141. Leptothrix --.-..--- 691

142. Diagram of the Motor Neuron ...... 693

143 and 144. Convolutions and Fissures of the Brain - - - 696
146 AND 146. Localisation of the Chief Functions of the Cerebral

Cortex - ........ 697

147. The Chief Motor and Sensory Tracts .... 698

148. Transverse Section of the Spinal Cord .... 700
149 AND 160. Distribution of the Cerebral Arteries - - - 703
161. Galvanic Battery- ....... 718

152. Cortical Centres of Speech ...... 749

153. Idbomotor Centres for Speech, Writing, etc. - - - 751

154. Base of the Brain, showing Arteries and Cranial Nerves - 780
155 AND 166. Segmental Algesic Areas .... 790, 791
157 TO 160. Areas of Distribution of Cutaneous Nerves - 806, 807
161. Pathology of Tabes Dorsalis ----.. 818
162 AND 163. Reflex Arcs of the Movements of the Pupil • 870, 872
164. Werner's Diagrams ...--.. 874
166. Distribution of Cutaneous Nerves to the Head - - - 880

166. Sense of Taste and Nerve Supply of the Palate - - . 882

167. Course and Connections of the Facial Nerve - - . 884

168. A Case of Facial Paralysis ...... 885

169. The Auditory Apparatus ...... 888

170. Wright's Pipette - - - - - - - - 906

INTEODUCTION

Those who ponder on general principles and inernods will have observed
that a considerable change has gradually taken place during the last half-
century in the methods of studying the science and art of

EVOLUTION. 1- . « , 1 ,

medicme. Formerly, men were content to observe the symp-
toms or effects of disease at the bedside and in the dead-house, and to
speculate on the etiological connection of these two series of phenomena.
Wherever the association of such phenomena during life and after death
was sufficiently constant they were spoken of collectively as a " disease "
when a group of symptoms without anatomical lesion constantly recurred,
it received a name and place among the list of " disorders." Then each
disease or disorder was taken as a separate entity, its anatomy, symptoms,
diagnosis, and treatment were described, and its various possible etiological
factors discussed ; and the result was known as '* Descriptive " or " Sys-
tematic Medicine." The guiding principle of this descriptive process was
the tracing from an assumed cause to a known effect.

In later times great advances were achieved, almost synchronously, in
two very different directions. On the one hand great improvements were
made in the methods of observing and investigating the symptoms or
effects of disease during life, and thus Clinical Medicine came into separate
existence. This stage was marked by the appearance in this country of
two very successful works — one by Dr. Samuel Fenwick, of London, on
" Medical Diagnosis," first published in 1869, dealing with the symptoms
and diagnosis of disease ; another by Dr. James Finlayson, of Glasgow,
entitled " A Clinical Manual," first published in 1878, dealing with the
methods of observing and investigating the symptoms of disease. On the
other hand, with the extremely rapid growth of chemical, biological, and
bacteriological sciences, and the elaboration of experimental methods in
the investigation of disease processes, a new school of pathology arose,
whose methods were based upon experiment, and whose leading principle
was the artificial production of a definite cause and the observing of its
effects. The extraordinary advances made by these means, and the new

xxi

xxii INTRODUCTION

light thus shed upon the science of medicine during the last twenty years,
form at once the wonder and delight of the civilised world.

As a result of the movement to which I have referred, and the growth in
the two directions named, treatises on Systematic Medicine, which attempt
to deal at all fully with both the clinical and the pathological aspects of
disease, have come to assume very considerable dimensions. In many of
them there seems to be a tendency to become more and more pathological
in their arrangement, and to treat diseases as separate entitiep, so that
students of clinical medicine and busy practitioners, whose daily work
consists of an endeavour to trace from effect to cause, have been heard
to complain that they do not always find in them the clinical aid
thev seek.

Immediately after embarking on medical practice I realised, as probably
many others have done, the importance for diagnostic purposes of review-
ing the various diseases or pathological conditions which
'""°™- might give riB« to a patient's leading symptom or symptoms,
and being unable to find precisely the information desired in any of the
current textbooks, I proceeded to keep a brief record of all the cases I
met with arranged under the heading of their leading symptom. This book
is based upon those records, which extend over many years, combined with
the valuable knowledge imparted to me at the bedside by my teachers —
more especially Dr. Charles Murchison, Dr. J. S. Bristowe, Professor
J . M. Charcot, and Sir William Broadbent. Hospital cliniques, at first of
a general and later of a more special kind, have always been at my com-
mand ; but it was at the Paddington Workhouse and Infirmary that the
idea of this work was conceived, its foundations laid, and the chief part
of its " skeleton " constructed. It would be hard to conceive circum-
stances better suited to the task, for our great poor-law infirmaries contain,
as all the world now knows, a vast and almost unexplored field of every
possible variety of disease, which can be studied from day to day fiom the
beginning to the end of its course.

As regards the plan and arrangement of this work, the subject will be

approached from the gtandpoint of sjonptomatology. The principle

throughout will consist of tracing from effect (sjmgtoms) to

cause (the morbid process in operation). The order of sequence

will be that which should be adopted in the examination of a patient.

I Thus, the fest^ chapter will give a general scheme for the examination of

a case, and will deal with certain general principles underlying methods of

I observation, diagnosis, prognosis, and treatment. In the second chapter

the physiognomy of disease will be discussed. The succeeding chapters

will deal seriatim with the symptoms and signs referable to the several

SPECIAL FEATURES xxiii

organs or anatomical regions of the body, and the diseases which may
cause those symprtoms.

Each chapter will be divided into three, unequal garts. Part A. will
treat of the sjfmyUms which may indicate disease of the organ or region
under discussion, the fallacies incidental to their detection, and a brief
differential account of the various causes which may give rise to those
s3rmptoms. Part B. will treat of the physical signs of disease in that
region, and the various methods used to elicit them. Part C, which con-
stitutes the major portion of each chapter, will be prefaced with a clinical
classification of the various maladies affecting that region, and a summary
of the routine procedure to be adopted ; and this will be followed by a series
of sections dealing with the several diseases, arranged according to their
clinical relationships. For example, in Chapter III., on The Heart —
Part A. describes and differentiates the various causes of breathlessness
palpitation, precordial pain, and the other symptoms which may be
indicative of heart disease ; Part B. describes percussion, auscultation, and
the other methods of examining the heart ; and Part C. deals seriatim first
with acute, and secondly with chronic cardiac disorders, classified and
arranged on a clinical basis.

Apart from the general plan and arrangement, there are two features

special to this work. The first part of each chapter, dealing with symptoms

and their causes, forms a feature on which great labour has

FBATTOEs ^^^ expended. To make each list of causes complete with-
out redundance, and to check the various data again and again
in the light of experience, has involved an expenditure of time quite out
of proportion to the space occupied. These lists will, I trust, be as useful
to others as they have been to me in obtaining a clue to diagnosis.

Another feature consists of the italicised paragraphs in Part C. standing
at the head of each section, which deal with a separate malady. These
emphasise the salient features by which a disease may be recognised and
differentiated from others belonging to the same clinical group. They are,
in fact, brief clinical definitions, and form, metaphoricaUy speaking,
" sign-posts " or guides in the process of diagnosis. If, after carefully
studying the lists of symptoms and their causes in Part A., and examining
his patient (Part B.), the reader turns to these italicised paragraphs in
Part C, the work will, it is hoped, serve as a " clinical index of diseases ";
for by following the plan laid down he will shortly find himself reading a
description of the diagnosis, prognosis, and treatment of the malady from
which his patient is probably suffering ; while adjacent to this are the
disorders which clinically, and very often pathologically, resemble it, and
for which in practice it is apt to be mistaken.

xxiv INTBODUGTWN

Such an arrangement as that proposed must inevitably lead to some
repetition, but this difficulty has been obviated to a certain extent by cross
references. I would also ask the reader to remember that nothing fixes
things so well in our minds, or aids us so much in tracing those analogies
to which I shall shortly refer, as constantly looking at the same facts from
a different point of view.

An attempt has been made to present the various diseases in some kind
of perspective by placing them as far as possible in order of importance
and using different sized types. The relative importance of different
subjects in medicine is largely a matter of opinion, and I cannot expect
to escape criticism in this respect.

It is a standing accusation against medical writers that they are care-
less in respect to literary style, and I fear that I shall not be found an
exception. I have striven to be intelligible rather than academic ; and
in general I fear that I must plead guilty to having endeavoured to foUow
the Duchess's advice to Alice in Wonderland, to " take care of the sense
and the sounds will take care of themselves.'' When so large an area has
to be covered, a certain amount of abbreviation is indispensable, and in
order to condense my material, it has been my practice to adopt a numerical
method of description. Some may take exception to this, though the
student will find it to his advantage in the acquisition of knowledge.

I may perhaps be pardoned for adverting to certain advantages which
appear to me to be associated with the method that I have adopted of

approaching clinical medicine. And first let me remark that
this method of diagnosis is not what has been called a '* pro-
cess of exclusion." It is a positive rather than a negative process, for by
carefully considering the various causal diseases which may be in operation
and balancing the evidence for and against each, the physician is guided*
not to the least improbable, but to the most probable diagnosis.

The advantages of passing in rapid review all the possible diseases which
may give rise to a patient's leading symptom, are very obvious to those
actively engaged in clinical work. It was Dr. Charles Murchison's method
in his bedside teaching ; and another equally great clinician. Dr. Matthews
Duncan, has aptly remarked : " If you do not know of a thing, you are
quite sure not to suspect it ; and in all cases of difficult diagnosis, if you do
not suspect the disease, you are almost certain not to find it." ^ But I am
not aware that any work has yet been published which adopts precisely
this plan of approaching clinical medicine.

This plan gives, I venture to think, a truer view of nature's facts than
one which deals with diseases as so many separate entities. We see a case

* *' Clinical Lectures on the Diseases of Women," 4th edition, p. 15.

ADVANTAGES xxv

in all its clinical and practical bearings. We not only Icam that the diag-
nosis of a patient's malady can at best be only a question of the greatest
probability, but with almost mathematical precision we can also assess the
probability or improbability of each of the other possible causes in opera-
tion. We leam further that all diagnoses can only be provisional, and
that the degree of probability of each possible cause changes from day to
day, like the coloured pattern of the kaleidoscope, as the course of the
malady unfolds itself before us.

It is, moreover, in clinical work carried out on these lines — where diseases
presenting analogous clinical phenomena are constantly being associated
together from different points of view — that the role of the imagination,
both in the investigation and in the treatment of disease, finds a legitimate
place. The recognition of a clinical likeness between diseases has often
led to the erection of a " working hjrpothesis " which by subsequent
research has been found to be correct. Many of our greatest discoveries
have been initiated in this way. It was, for instance, a process of this
kind which led to the discovery that a large number of, perhaps all,
pyrexial disorders are of microbic origin. There are still a number,
notably measles, small-pox, and scarlatina, in which such a working hjrpo-
thesis, based on clinical resemblances, forms at present the fidl extent of
our knowledge ; but so precise are these foundations that the microbic
nature of these diseases is never doubted. Hypotheses framed in this
way should always be tested and confirmed in the laboratory and dead-
house, whenever the morbid conditions can be produced experimentaUy,
or when they are attended by fatal results. But unfortunately there are
still a great many diseases, such, for instance, as the two great groups of
clinical conditions we call hysteria and neurasthenia (conditions which
form a not inconsiderable portion of the practitioner's daily work), which
cannot, excepting in the most isolated instances, be observed in the dead-
house, and which have not yet been produced in animals. In these cases
the method of analogy or comparison to which I have just referred is not
only a valuable means of investigation, it forms almost the only means we
have.

It is given only to few to devote the necessary time to laboratory
research ; but all can study their cases at the bedside in the way indicated,
and many a valuable and often unrecorded idea as to treatment will
occur to the practitioner who thinks out and traces clinical analogies
between diseases.

There is yet another advantage which has always appeared to me to
accrue, especially to the young observer, by this process of balancing
evidence and comparing diseases. It not only impresses important facts

xxvi INTRODUCTION

upon his memory, but it constitutes one of the best possible means of
training him to habits of accurate and complete observation, and of
systematic and productive thought. The scope of his horizon is widened,
his faculty of systematising his knowledge becomes by practice wonder-
fully increased, and his reasoning powers strengthened and corrected. He
finds intuitively that without accuracy in respect to the most minute details
he may be led astray in the more important ones, that without system in
the arrangement of his facts he will never be able to attach the proper
significance and importance to each ; and finally, that without judgment
in attaching due weight to each item of evidence, his conclusions may be
erroneous although his premises and facts are correct.

I have now described the scheme of this work, its purposes and scope —
in a word, the ideal which I hoped to compass ; and I believe no one could

approach a task of this kind without realising the re-
sponsibilities and dimculties mvolved m its execution.
Amidst the bewildering records of medicine there are many excellent
treatises both on systematic medicine, the medicine taught in the schools,
and on one or other of the several departments of clinical medicine.
These deal with their respective subjects in a manner which I cannot hope
to rival, and they have been to me an abundant source of instruction, but
they have afforded me no exact precedent or guide along the path I wished
to travel. The contemplation of the wide range of knowledge and ex-
perience required, of the immense advances which have recently been
made both in the theory and practice of medicine, of the supreme impor-
tance of the subjects here dealt with> involving as they do questions of life
and death, has filled my mind with a painful sense of the obligation im-
posed upon me to sift my facts, and to cull my knowledge, truly, from all
sources, but, before all, to obtain my material as far as possible by careful
observation and patient thought from the book of nature which lay open
before me from day to day at the bedside in infirmary, hospital, and
private practice.

In these circumstances I have gladly availed myself of the help and
advice of many friends, and there are some to whom special^acknowledg-
ment is due. In certain parts of the chapter on fevers, notably on scarlet
fever, measles, diphtheria, and enteric fever, I have had much valuable
advice and suggestion in the revision of the proofs from my old friend
Dr. Foord Caiger. Similarly in the subject of aneurysm and in parts of
the subject of pulmonary disease I am indebted to Dr. Robert Maguire, in
parts of the chapter on diseases of the throat and nose to Dr. St. Clair
Thompson and Dr. Scanes Spicer, in parts of the section dealing with
serum -therapeutics to Dr. George Dean, in parts of the chapter on diseases

RESPONSIBILITIES xxvii

of the heart to Dr. Alexander Morison, and in parts of the chapter on the
urine to Dr. C. 0. Hawthorne. The illustrations, with few exceptions,
are taken from actual cases, and have been drawn specially for this book
under my own supervision ; my grateful thanks are due to the artist>
Mrs. Stanley Berkeley, a Royal Academy medallist, who has lent her talent
to enrich these pages with drawings which are not only accurate but, as
far as scientific drawings can be, artistic. Finally, it is difficult for me
to express in measured terms my indebtedness to my wife, who has
assisted me in the elaboration of this work during the greater part of four
years. Her skill and knowledge have largely helped to give it such com-
pleteness as it may possess ; her patient industry has afforded me not only
assistance, but example ; and her companionship and encouragement have
made many rough places smooth, and have often transformed what at times
seemed to be a laborious and interminable task into a pastime.

T. D. SAVILL.
March, 1903.

A SYSTEM OF CLINICAL MEDICINE

CHAPTER I

CLINICAL METHODS

Prdiminary Definitions — Case-Taking — Methods of Diagnosis, Prognosis y
and Treatment — Rules for Clinical Investigation,

§ 1. DeftnitioiiB. — ^Disease is a departure from health, and is manifested in
an individual during life by sjrmptoms. These are of two kinds — " sub-
jective symftomSy^^ which are recognisable only by the patient, and present
no external indication, such as pai^, itching, or a feeling of chilliness ;
and " objective symptomSy*^ ^ which can be detected by the observer — e.g.,
abdominal enlargement or dulness on percussion. The word " symptom "
is used in two senses. Sometimes it is used in a general sense to indicate
all the subjective and objective evidences of a disease ; but more usually
it is employed in a narrower sense, as synonymous with the subjective
manifestations of a disorder. Confusion is obviated by using the term
" subjective symptoms " when the latter sense is specially intended.
Objective symptoms are usually spoken of as signs ; and those objective
symptoms which are made out by physical examination are known as
physical signs.

Just as the value and significance of physical signs depend on the skill
and experience of the physician who observes them, so the significance of
subjective symptoms has to be weighed and considered in relation to the
character and constitution of the patient who complains of them. Thus
a certain symptom may appear trivial and unimportant to a patient of
strong character not addicted to introspection, although serious disease
may be present ; whereas in delicate women with susceptible nervous
systems every subjective symptom, however slight, may cause great
anxiety or exaggeration, and even real suffering. Submammary pain, for
instance, in the first might indicate aneurysm ; in the second, hysteria.

General {or constHutional) symptoms are those which relate to the whole
body, such as debility or pyrexia.

* These words " subjective " and " objective " are borrowed from philosophy.
Subjective reality is reality which exists in the mind only, whei^das objective reality
is that which can be demonstrated by means of tangible, visible, or outward signs.

2 CLINWAL METHODS [ § 2

A UUent disease is one which is unattended by any very obvious symp-
toms. Thus, we speak of latent puhnonary tuberculosa when a patient
suffering from tuberculosis of the lung has none of the more usual and con-
stant symptoms of that disorder. Physical signs are not necessarily
absent in latent disease, but they are often difficult to detect. Some
writers speak of a malady as being latent when the pain, which is usually
a prominent feature of the disease, is absent. Thus, pericarditis is
ordinarily attended by a good deal of pain, but this is absent in the latent
form of pericarditis which frequently complicates rheumatic fever, and
in the latent peritonitis which complicates enteric fever.

A paroxysmal disorder is one which oomee on in the form of attacks separated by
intervals of comparative health. Each attack or paroxysm consists of a stage of
invasion (usually more or less sudden), leading to an acme, and followed by a gradual
decline in the severity of the symptoms. As instances of paroxysmal disorders may
be mentioned Paroxysmal Tachycardia, Angina Pectoris, Epilepsy, Nervous Faints
and Flush Storms, and Paroxysmal Hsemoglobinuriaw

The clinical features which all paroxysmal disorders present, and a close study of
those features which admit of a pathological explanation, point to the probability of
an origin in the sympathetic system, and especially its vaso-motor portion.

§ 2. Case-Taking. — In clinical investigation, or case-taking, our object is,
first, to elicit all the data of the case ; and, secondly, by reasoning based
on those data to arrive at its Diagnosis, Prognosb, and Treatment. It
will be found in actual practice that everything turns on the diagnosis ;
that is our first and principal object ; the prognosis and treatment follow
from this.

The investigation of a case consists of two parts : (A) The Interrogation
of the Patient, and (B) the Physical Examination. Students should
always accustom themselves to learn all that is possible by interrogation
before proceeding to the physical examination.

A. By Interrogation of the Patient we learn —

(a) What is his chief or dominant symptom ;

(b) The facts concerning the present iUness ;

(d) Hid family history.

Throughout the interrogation of the patient it is well to follow three

GENERAL RULES :

(1) Avoid putting what barristers call " leading questions " — i.e., questions
which suggest their own answer — e.g., "Have you had a pain in the
back ?" suggests an obvious answer to the patient. It might be put thus :
*' Have you had any pain, and if so, where ?" The patient should be
encouraged to tell his own story, without interruption. Moreover, the
very words he uses should be recorded in inverted commas, and on no
account should the words of the patient be translated into scientific terms.
Some say that leading questions are permissible when the patient is very
ignorant and stupid, but these are the very cases in which leading questions

S 8 ] OASE'TAKINQ 3

should be specially avoided. The only legitimate way of putting a leading
question is in an alternate form — e.g., " Have you suffered from diarrhoea
or constipation ?" Time, patience, and tact are necessary to elicit the
true facts of the case, without irrelevant detail. Our object is to learn
what the p&tient feds and knows, not what he thinks of his disease ; and
our patience is often sorely tried by a long story of his own or his previous
doctors' views on his case. Our record should be comprehensive. Including
all important data, negative as well as positive, yet concise — i.e., excluding
irrelevant facts. Only experience and a knowledge of medicine can teach
us what is or is not relevant. The beginner, however, should strive after
completeness rather than conciseness.

(2) A chronological order should always be adopted, both In eliciting and
in recording the facts. Nothing is more wearisome than to wade through a
mass of verbiage which mixes up dates. Dates should be recorded always
in the same terms. It is very common, for instance, to read in students'
reports that " breathlessness began in the year 1892," " palpitation started
when the patient was aged forty," " the dropsy came on three years ago."

(3) Always adopt a kindly and sympathetic manner. Not only is it our
bounden duty to be considerate and patient with those who suffer, but by
entering into the spirit of the patient's sufferings we can often get at more
important facts, and a truer narration of them, than can one whose harsh
or abrupt manner causes the patient to shrink up like an oyster into its
shell. Put your questions in as simple and non-technical a form as possible,
and be sure that the patient attaches the same meaning to the words as you
do. Much will depend on the tact of the physician, and two very good
rules may here be added — viz.. Never put questions bearing on venereal
disease before the husband or wife of the patient ; never inquire concerning
a family history of consumption or cancer before a patient whose illness
is likely to be of that nature.

(a) The Chief or Cardinal Symptom. — The first question to ask a
patient should always be the same : " What do you complain of ?" Special
attention should be paid to the symptom for which the patient seeks
advice or is admitted to hospital, because it is this symptom which guides
most of our subsequent inquiries. It should always, as far as possible,
be recorded in the patient's own words. This book is based upon the
patient's cardinal symptom; and in the following chapters I shall, after
each cardinal symptom, allude to the principal conditions for which it
may be mistaken. The best way to avoid error in this respect is to
verify your observations by repeating your examination again and again.

(b) History op the Present Illness. — It is better to investigate the
present illness first, before the previous and family histories, because it is
closely connected with the patient's disease, and because we are tracing
backwards from effect to cause. A good question to start with is : " When
did you cease work ?" or, " When were you last quite well ?" Remember
that the present illness dates from this to the time when the patient came under
observation. Our questions should be directed to ascertaining three facts

4 CLINICAL METHODS [ § 8

of importance — viz., the precise manner of commencement of the disease,
whether sudden or gradual ; the date when the patient ceased to work ;
and the date when he took to his bed. Then the evolution of symptoms
can be traced step by step in the order of their development — always in
chronological order. It is useful also to know whether he has recently been,
or is now, under medical treatment, not only because the symptoms may
have been modified in this way, but also because one of the most important
ethical principles of the medical profession may be involved.^ In all of
these inquiries the three general rules above given apply (p. 2).

(c) The Previous History of the patient bears largely on the etiology,
or causation, of his illness, and comprises two orders of facts — viz., (1) those
relating to any illnesses the patient may have had before the present one ;
(2) those concerning his personal habits and surroundings,

(1) iJnder the former heading, note in chronological order all ailments
the patient has suffered from prior to the present one, with the dates of
their occurrence and their duration — e.g., contagious diseases of childhood ;
and especially such ailments as venereal disease, rheumatism, and gout.
If the attacks have been at all obscure, it is desirable to add a few of the
leading symptoms to prove the nature of the alleged attacks, and in such
instances inverted commas should be freely used. For instance, " rheu-
matism " is a vague term which may mean any disease attended by pains
in the limbs, such as alcoholism, syphilis, tabes dorsalis, or neurasthenia.
The subject of syphilis should always be approached with delicacy in the
case of women. Indirect information may often be gained by inquiring
for prolonged sore throat, followed by loss of hair, by eruptions, or pains
or swellings of the cranial or other bones. In married women a series of
miscarriages or still-births, or children born with eruptions or snuffles,
may have the same significance.

(2) The occupation, home surroundings, and previous habits as regards
exercise and food should be inquired into. The daily amount of alcohol
taken, and its kind (wine, beer, or spirits), should always be noted ; and
also the time of day at which it was taken, because far more harm may bo
done by " nips " between meals (without ever getting actually drunk)
than by ten times the quantity taken with meals. Finally, we should
ascertain whether the patient has resided abroad, especially in malarial
districts. In females, the previous state of the catamenia, and the number
of pregnancies, miscarriages, or still- births, should be noted.

(d) The Family History may, like the previous history, have a causal
relationship to the patient's malady. The age and state of health if
living, age and cause of death if dead, of near blood relations, should

* By-law CLXXV. of the Royal College of Physicians of LoudoD runs as follows :
' • No Fellow, Member, or Licentiate of the College shall officiously, or under colour of
a belSevolent purpose, offer medical aid to, or prescribe for, any patient whom he knows
to be under the care of another legally qualified Medical Practitioner." This is perhaps
the most important guiding principle in tlie ethics and etiquette of the medical pro-
fession. On the other hand, this law gives us no proprietary right in a patient because
we have once prescribed for him or his family. He ceases to be our patient directly he
ceases our treatment for that particular ailment.

§2] GASE'TAKIN.O 5

always be noted — i.e., father and mother, brothers and sisters, sons and
daughters. Inquiry should also be made as to whether any members of
the family (parents, grandparents, brothers, sisters, uncles, aunts, or
cousins) have suffered from consumption, cancer, acute rheumatism, gout,
nerve diseases, insanity, asthma, heart disease, apoplexy, and especially
those diseases to which the patient himself seems liable.

B. The Physical Rraminatian (i.e., the State on Admission, or the
Present Condition) may with advantage be prefaced by a few general
remarks on how and what to observe.

(1) Here, again, having learned by interrogation our patient's chief
complaint, we should ask ourselves, Is there any striking or pre-
dominant SIGN OR appearance (Latin fades) ? The importance of
INSPECTING our patient cannot be overestimated. In these days of
scientific instruments we are too apt to forget the use of our faculties.
By simply using our eyes many important data may be learned besides the
colour of the skin, the general nutrition, the attitude or decubitus, and
the facial expression. For instance, the manner in which a patient answers
questions is often the first clue to hysteria, and a peculiar mode of speech
is one of the pathognomonic symptoms of general paralysis of the insane,
disseminated sclerosis, and other diseases. Moreover, with experience we
can by thb means form a conclusion as to the kind of patient we have to
deal with. Again, never be in a hurry ; it is only by taking time that we
can fully appreciate all the points presented to our view. This habit of
" observing " the patient is only developed by long practice ; but it will
never be developed if the young physician allows himself to be infected by
the hurry of modem times.

(2) It is important always to commence our examination with that organ
TO WHICH THE SYMPTOMS ARE MAINLY REFERABLE. Some teachcrs direct
their pupils to examine and report on the physiological systems always in
the same order (first the heart, then the lungs, then the digestive system,
and so forth), whatever may be the malady. But such a course has, to
my mind, three objections : (i.) The student goes about his work in a
mechanical fashion ; (ii.) if the patient suffer from some serious disorder,
such as peritonitis, he may be seriously injured by a thorough investiga
tion of the chest and other parts ; and (iii.) in many cases it is a waste of
time to examine all the organs with equal thoroughness. The same
educational advantages and experience can be obtained by the other
method, and in that way we come to the most important facts first. As a
general rule, the most important data should be mentioned first.

(3) In all cases every organ in the body should be carefully
EXAMINED ; for although we may find in one physiological system sufficient
mischief to account for the patient's symptoms, the other organs may
reveal changes which considerably modify our treatment, our prognosis,
and even our diagnosis. Whatever order is adopted, the student should
not wander from organ to organ, but examine each physiological system

« CLINICAL METHODS [ § 2

thoroughly before proceeding to the next. It is well to get into the habit
of adopting some such order of physical examination as the following :
F%r9ti note the general condition ; secondly ^ examine the organ chiefly
affected ; thirdly, the other organs in the following order : Thorax (heart and
lungs), Abdomen (alimentary canal, liv^r, spleen, and genito-urinary
system), Head and Limbs (nervous and locomotor apparatus). Further
details are given in the scheme below, but for the thorough investigation
of the organ chiefly affected reference must be made to the chapter dealing
with the diseases of that organ.

The examination should always be carried out gently, and without undue
exposure. In serious cases, especially when the heart or lungs are involved,
it is often well to postpone a thorough examination of some organs, so as
not to risk harming the patient by exposing or fatiguing him. At the
same time, the young physician should never allow modesty to prevent
his making a thorough examination. This rule is especially necessary in
patients of the better class, but a little firmness, tact, and a courteous
demeanour will generally enable him to perform what is a duty both to
himself and his patient.

:{m;i:h>

OF CASE-TAKING.

A. INTERROGATION OF PATIENT,

(a) The patient's chief or Cardinal Symptom.
(h) Data concerning the Present Illness.

(d) The Family History.

B. PHYSICAL EXAMINATION (i.e., Present CondUionr-Give Date).^

(a) The general condition may be summarised mainly under three head-
ings : (i.) The Physiognomy or expression (especially in acute
disease (Chapter II.) ; (ii.) The Decubitus, Attitude, or Gait,
especially in chronic disorders (Chapter II.) ; (iii.) The Nutrition,
General Conformation, and any Eruption on the Skin (Chapter
XVIII.). The temperature should be taken ; and any bed-sores
noted.

(^) Chest.

I. Cardio- Vascular System. (Chapters III. to V.)

Symptoms. — Breathlessness, palpitation, cardiac pain.
Physical Signs. — Pulse : rate, rhythm, tension, arterial wall.
Heart : apex-beat, percussion area, auscultation, dropsy.

^ This scheme gives only the chief points which should be noted about the different
physiological systems, with the object of excluding disease. For an exhaustive
examination, such as must be made of the organ to which the patient's symptoms
are mainly referable, the student should refer to the chapter dealing with the diseases
of that organ.

§ 2 GA^E'TAKINQ 7

II. Respiratory System. (Chapters VI. and VTI.)

Symptoms, — Cough, expectoration, dyspnoea, pain in chest.
Physical Signs, — Rate of respiration, inspection, palpation,

percussion, auscultation.
Examine throat and noso.

III. Alimentary Canal. (Chapters VIII., IX., X., and XI.)

Symptoms, — Appetite, discomfort after food, nausea, pain,
state of the bowels, colour of motions.

Physical Signs, — Examine mouth and tongue. Physical
condition of abdomen as regards distension, and presence of
fluid or tumour (inspection, palpation, and percussion).

IV. Liver. (Chapter XII.)

Symptoms, — Pain, jaundice.

Physical Signs. — Size (palpation and percussion), surface (if
accessible), tenderness.

V. Spleen. (Chapter XII.)

Any enlargement (palpation and percussion) or local pain.

VI. Urinary System. (Chapter XIII.)

Symptoms, — Any undue frequency of, or difficulty in, mic-
turition. Any dropsy or pain.
Physical Signs —

(i.) Urine : quantity, colour, reaction, specific gravity,
albumen, blood, sugar, deposit (microscopical ex-
amination),
(ii.) Kidney, — Any enlargement, mobility, or tenderness.

VII. Generative System. (Chapter XIV.)

Menstruation, frequency, duration, quantity, intermenstrual
discharge.

{d) Head and Iambs.

VIII. Nervous System. (Chapter XIX.)

Sym/pioms, — Intelligence, sleep, neuralgia, etc.
Physical Signs, — Muscles : paralysis, spasm, tremor, char-
acter of walk. Reflexes y deep and superficial.
Sensation for touch, pain, temperature.
Cranial Nerves, — Vision, pupils, movements of eyes, fundi.
Movements of face, tongue, and palate. Hearing. Smell.
Taste.
Sympathetic System.— Flush storms, trophic lesions, obscure
sensations.
(e) Blood.

In anaemic and some other cases the blood must be examined
(Chapter XVI.).

8 CLINICAL METHODS I § 8

Progress of Case. — ^Notes (daily of acute or febrile cases, twice a week of
subacute, and once a week of chronic cases) should be made of the progress
of the case ; and much care is required here to avoid redundancy on the
one hand, and on the other to record completely all important changes, or
any fresh symptoms, and the effect of the treatment adopted. In acute
febrile cases there ought to be a daily note, and the pulse, respiration, and
temperature should be noted several times daily. In chronic cases it will
be sufficient to note, once a week, the persistence of the prominent symp-
toms or any change in the symptoms. In all cases any sudden change in
the patient's symptoms or general condition should be noticed at once.
Each note should have special reference to the previous one ; and before
taking a fresh note, the previous one should be read over. The treatment
and its effects should always be incorporated ; thus, if the patient has been
ordered diaphoretics or purgatives, record should be made of the state
of the skin or bowels.

History Sheets, Charts, Diagrams, etc.— A history sheet for recording the history of
a patient should be ruled with one vertical line down the page one-thiid from the left-
hand margin, so as to give space for information learned subsequently. It should
have printed headings and spaces at the top, thus :

D'agnosis. (Space here for primary and secondary disease, filled in by physician

afterwards. )

Name Age Sex Ocoapation

Address Date of admission

Chief symptom on admission

Date of discharge '

Temperature charts are of the greatest use to record the temperature and other
features of diurnal variation

Outline diagrams of the various regions of the body are now prepared, and are
very useful.

A kind of shorthand code for physic il signs is advocated by some authors, and. when
once learned, may be useful in saving time and space.

§ 8. Examination of Children and Infants. — Here the same general rules apply as to
interrogation and physical examination, and we should first endeavour to ascertain
the child's leading symptom, either from the patient or the relatives. There are
however, certain additional rules upon the adoption of which much of our success
with children will depend.

1. First endeavour to establish friendly relations with your little patient. • This may
be done sometimes by appearing not to notice the child when you first enter the room ;
after a while it may make advances and investigate your watch-chain or ring. A child
dislikes being starod at. Time should always be given for the child to become accus-
tomed to your presence, and anything like abruptness will defeat your aim.

2. The questions put to the child should always be of the simplest character — e.g.^
" Where does it hurt you ?" From the mother you may learn the age up to when the
child remained healthy, the symptoms of the present and previous illnesses. In the
case of an infant ask whether is was a full-time child, if bom with instrumental aid,
whether it was bom healthy, or whether it developed a rash or " snuffles," and whether
breast or bottle fed. If the child is past early infancy, the same questions may still be
put, and in addition inquire when it began to walk, and when dentition commenced.

$4] METHODS OF DIAGNOSIS 9

Carefully inquire as to its present and past diet, as to its appetite, and the state of the
bowels. Ask also how long it sleeps, bearing in mind that children require much more
sleep than adults. Then inquire for any recent illness in other members of the family.
Physical Examination. — Valuable as aiierUive observation may be with adults, it
becomes quite indispensable with children, who cannot accurately describe their
sensations. Much may be learned while you sit and allow the child to get accustomed
to your presence. Notice its expression, the brightness of its eyes, its attitude, the
colour of its skin, the state of nutrition, its size as compared with age, its movements,
the condition of its lips (moist or dry), the character of the breathing, the sound of its
voice. If it cries, inquiry should be made whether this is constant or only at times.
Congenital syphilis may be plainly depicted on its face or skin. If the child be asleep
when first you enter, do not wake it, but notice all the above before it is disturbed.
The limbs of a healthy child should be constantly on the move ; drowsiness, dulness,
and listlessness are signs of pyrexia, and especially that of the contagious fevers.
The hands are instinctively moved towards a seat of pain — e.g., the head in meningitis
The state of the temper is altered in the prodromal stage of most diseases ; but it is
markedly peevish in the prodromal stage of meningitis. For other facial alterations,
see Faciei (§ 12). When the child is undressed for examination, the back of the chest
should be examined first, while the child looks over the mother's shoulder at someone
who attracts its attention with a bright object or a bunch of keys. The binaural
stethoscope is the most useful under these circumstances. Percussion should be
delayed until the end of the examination.

§ 4. Methods of Diagnosis, Prognosis, and Treatment. — ^Diagnosis, prog-
nosis, and treatment are the objects we had in view in eliciting all the facts
concerning the patient by the process of " Case-taking." Of these three,
Diagnosis — which, as the Greek woid (hicuyvfoais) implies, means the dis-
tinguishing or discernment of the disease — is by far the most important.
Everything necessarily hinges on that, because without the recognition
of the disease, rational prognosis and treatment are impossible. It will
be well, therefore, to consider how the data we have elicited may be
utilised in order to arrive at a diagnosis. Several different methods are
employed :

The method usually adopted, which is the outcome of the student's
studies in systematic medicine, is to erect a hypothetical diagnosis, and
to see whether the patient's symptoms tally with the description of the
disease. When a child, for instance, with disorderly movements comes
before us, the diagnosis of chorea at once occurs to our minds. The age of
the patient, character of the movements, and all the obvious features of
the case appear to correspond with that disorder. It does not seem
necessary to consider any other suggestion. This method answers well
enough in straightforward, well-marked, typical cases ; but in cases
presenting anything unusual or atypical considerable difficulty may be
experienced.

Another method of making a diagnosis is by a process of exclusion ; that
is, after studying the diseases which might possibly be in operation, we
arrive at our diagnosis by excluding those which the disease least resembles.
In 3uch diseases as enteric fever, where the symptoms are few in number,
this may be the only method possible. The patient, for instance, is
suffering from a moderate degree of pyrexia, the illness came on gradually ;
that is all we may know about the case. There are many possible causes

10 CLINICAL METHODS [ § 4

of such a condition, but we arrive at the conclusion that it is probably
enteric fever, because all the other possible diseases are rendered im-
probable for one reason or another.

The third method consists of noting the cardinal symptoms and balancing
the evidence for and against all the possible causes which might give rise to
it. In this method, after having elicited all the facts of the case, we return
to the patient's cardinal symptom, enumerate in our own minds the various
causes which might give rise to that symptom, and balance the evidence
adduced by the other facts of the case for and against each one in turn.
It may strike some as being a little tedious, but it is not so when we have
got into the habit of employing it. It is certainly the one best adapted
for the elucidation of obscure or atypical cases ; and under all circum-
stances it presents a truer picture to our mind, because diagnosis can
never be a matter of absolute certainty. At most a diagnosis is only a
strong probability, and this method enables us to ascertain the exact
amount of probability in each disease. Even in the simplest and most
typical cases it is a good mental exercise for us to keep in mind the other
lesions which might produce the same symptom, and then we are always
on the lookout for possible errors, and ready at any moment to review
the diagnosis — a correct mental attitude when in presence of Nature's
phenomena. The chapters which follow are based on this method.

ExAHFLB. — Let us suppose, for instance, that the patient, a pale young woman,
aged twenty-three, comes to us complaining of Tomiting blood t.e., hematemesis).

First, we ascertain and verify this, the leading symptom, and find that she has really
vomited a considerable quantity of blood.

Secondly, we interbooatb her as to the history of her present illness, her previous
and family histories, and we find that she has suffered for several years from symptoms
pointing to dyspepsia, and that latterly there has been severe pain in the epigastrium.
There are always four features we have to investigate about every pain — its position,
character, degree, and constancy ; and we find that this epigastric pain is a sharp pain,
not constant, but coming on Portly after taking food, and that it is followed and
relieved by vomiting. The other details of the case we will omit for the sake of brevity.

Thirdly, we proceed to the physical examination, first of the abdominal organs,
but this reveals nothing abnormal. Then we go through the other physiological
systems in order, observing (a) her General Condition (noting, for example, how pale
and thin she is, and how weak she seems) ; (6) examining the Chest (oardio- vascular
and respiratory systems) ; (c) the Head and Limbs (nervous system) ; (d) the Blood
must also be examined, because anaemia (poverty of blood) may be inferred from the
pallor of her skin.

Having elicited all the data (taken the case) by interrogation and physical examina-
tion, we return to the cardinal symptoms — ^haematemesis ' — ai\d consider its various
causes (sec the section on Hsematomesis) seriatim, taking the most probable cause in
this case first.

^ Here there was no difficulty about identifying or selecting which was the chief or
roost important symptom ; but in another case uie anaemia (or the vomiting or epi-
gastric pain) might he the more serious or prominent symptom, the haematemesis
consisting, perhaps, of a few streaks of blood. Then we should deal with the anaemia
in the same way as haematemesis is here dealt with. Sometimes a good deal depends
upon our choice of which is the " leading symptom." for it is not always the most
prominent which is the most serious and important ; and by an error in this respect
we may bo led far afield of the true disease. Sometimoa. howovor, it is useful to
change the point of view we take of the case, by regarding it from another standpoint
or leading symptom.

§4] METHODS OF DIAGNOSIS; PROGNOSIS 11

(a) SiMFLB Ulcer of thb Stomach.

For : (L) The profuseness of the hsematemesis ; (ii.) the character of the pain
(brought on by food, relieved by vomiting) ; (iii.) the history of dyspepsia ;
(iy.) the age and sex of the patient.

Against : (i.) No tenderness in the epigastrium

(b) Cancer op the Stoiuoh.

For : (i.) The vomiting of blood ; (ii.) pain in the stomach ; (iii) palbr and

emaciation ; and so on.
Against : (i.) The blood vomited was too profuse, and had not the character

special to cancer (coffee grounds) ; (ii.) the pain was only produced by

food, and entirely disappeared after vomiting ; (iii.) age of patient much too

young.

For : (i ) The profuseness of the hsematemesis.

Against : (i.) Absence of abnormal signs in the liver ; (ii.) absence of ascites,
piles, and other symptoms of portal obstruction.

(d) Other and less probable dlagnoses can be discussed in like manner, though

each of these may be more summarily dismissed thus : Vicarious menstrua-
tion would not account for the dyspepsia, acute epigastric pain, and other
symptoms. Leucocythamia, Scurvy, and oiher blood conditions, if present,
would present the other symptoms of those maladies ; and so on.

It follows, therefore, that the balance of evidence is in favour of (a) Simple Ulcer
OF the Stomach, partly because of the weighty arguments in its favour, and partly
because the only argument against it is not vital, for tenderness may be absent when
the ulcer is situated on the posterior wall of the stomach. Indeed, if a numerical
value were given to each of the ** reasons ** for and against, it would be possible to
express the precise degree of probability in each disease in the form of a mathematical
ratio. This method may at first sight seem tedious, but after a little practice it
becomes automatic and extremely simple ; and it takes much less time than is here
implied.

Prosnosis (from the Greek word TrijoyvaxTts:) is a " foreknowledge " of
the events which will happen — t.e., of the probable course the disease will
run. Nothing but wide experience, combined with careful and minute
observation, will enable a physician to prophesy with any approach to
accuracy. It will, however, be useful to bear in mind that the prognosis
of a case depends upon four circumstances — viz., (1) the usucU course,
duration, and event of the disease in operation (phthisis, for instance,
runs a prolonged course, and until lately the event was almost invariably
fatal) ; (2) the presence or absence of untoipard symptoms (e.g., profuse
hsemoptysis in phthisb) ; (3) the presence or absence of complications
(which are sometimes more fatal than the disease itself — e,g,, enteric and
many other fevers are fatal chiefly by their complications) ; and (4) the
causes which are in operation, including among the predisposing causes
such data as age and sex (bronchitis, for example, in middle life is not a
serious affection, but in infancy and old age it is one of the most fatal
diseases in the Registrar-General's returns). More reputations are wrecked
on the rock " Prognosis " than on any other.

As practical hints to the young physician, I would advise him — (1) Never
to commit himself to a prognosis unasked, or before the effects of treatment
have been noted. (2) It is also well to impress upon the friends that a
'* physician " cannot hope to be also a " prophet "; and that prognosis

12 CLINICAL METHODS [ § 5

may depend on many factors in the case which are not yet revealed. The
medical work in connection with life insurance is largely a question of
prognosis.

Treatment is what the patient comes to us for ; and it may be of three
kinds : (1) In Radical treatment (also called Curative or Rational) our
object is to cure the patient of his disease by the removal of the cause.
This is the only truly scientific treatment, and it is based mainly upon a
knowledge of the pathology of the malady. (2) Symptomatic treatment ia
directed only to the relief of the symptoms. In some incurable maladies
symptomatic treatment is the only kind that is possible, and all that we
can do is to ease the passage to the grave. But in the practice of busy
practitioners, the trouble and time needed for thorough investigation
often lead to the adoption of the latter at times when a more radical treat-
ment would be possible. There is an unfortunate tendency to fall into
a routine of symptomatic treatment which we should constantly guard
against. Both Radical and Symptomatic treatment may be either internal
or external on the one hand, and either medicinal or dietetic and hygienic
on the other. (3) Preventive treatment has within the last quarter of a
century developed almost into a separate science, the science of Hygiene
or State Medicine.

§ 5. General Rules in Clinical Investigation. — There are certain habits
which the student should strive to cultivate when he comes to the practical
aspect of his profession ; and he should remember Thackeray's saying :
" Sow an act and you reap a habit ; sow a habit and you reap a character ;
sow a character and you reap a destiny." Clinical medicine depends
more than anything else on ac<jurate, complete, and well-directed observa-
tion, and there are five hints I would give to the student in this connection,

1. Avoid superficiality in your observations. Do not try to see many
cases in one day, but rather one or two cases continuously from day to day,
so that you may follow a given malady throughout its entire course. It
is of more value to follow up one case in this way than to see a dozen on
one occasion only. Practical knowledge must be acquired gradually.
The thought will often occur to the student how slowly he progresses with
his clinical knowledge. This is partly real, partly apparent. It is partly
apparent because a student does not realise at the time the value he derives
from listening, for example, to the same cardiac murmur over and over
again. It is partly real because it is only by patiently devoting the
necessary time to the study of the same case from day to day that he will
learn to make his observations adequate, thorough, and precise. That
is why many a brilliant intellect falls behind, and many a plodder comes
to the front in our profession. It is vain to attempt to substitute genius
for patient industry in this arena. You must learn for yourself the effects
of this or that line of treatment ; learn to correct and control the observa-
tions you make one day by your observations of the morrow ; and above
all, try to learn what is the sequel or termination of the case, especially

S 6 1 GENERAL RULES 13

in such instances as may lead you to the dead-house. There, more than
anjrwhere else, the most brilliant diagnosticians learn from their own errors
more than from a multitude of successful cases.

2. Do not strive after whU is rare and curious. It follows, as a matter of
course, that, other things being equal, a fact is more important in propor-
tion as it is common. Moreover, by studying only the exceptions to a
rule, our minds will have a distorted view of clinical phenomena. Do not
therefore, be led astray by those pedants who seek after the singular and
uncommon. It is well to see rare cases when the opportunity offers, by
all means, but be careful that you mentally register them as rare.

3. Do not study only acute and severe cases. It is true that in acute
diseases there is often more to be done, more heroic and decisive effects to
be produced, or apparently produced, and therefore more credit and
renown to be obtained. But we shall find in actual practice not one-
tenth, perhaps not one-hundredth of our patients will be suffering from
these complaints. Our success, therefore, in practice, whether measured
by that laudable satisfaction at having done one's duty, or by the pecuniary
reward of which every earnest labourer is worthy, will depend very much
on our experience of, and our ability to treat, chronic and what we are too
apt to call trivial complaints. For one case of Graves' or Addison's
disease, the student will, I venture to think, have a hundred cases of
dyspepsia, chronic rheumatism, or chronic bronchitis. In the treatment
of such complaints the greatest judgment and thoroughness are some-
times needed. No sudden or startling effects can be produced. Chronic
diseases require chronic remedies, and it is only by experience that one can
learn to produce those gradual effects which lead to a successful issue.

4. Be accurate in your observations. State facts precisely as you find
them, no matter whether they accord with your hjrpothesis or not ; and
state only what you find and know to be the truth. The study of clinical
medicine, like the study of any other of Nature's phenomena, should
inculcate in the mind of the student a love of truth. It is impossible to
have any dealings with Nature without learning that truth is the key
to the discovery of her secrets. Accuracy is one form of truth, and it is
only by repeatedly going over your observations, and sifting the patient's
statements, that you can insure accuracy.

5. Be systematic in the arrangement of your data^ for it is only by a
systematic arrangement that you can attach the proper significance and
importance to each, and get a firm grasp of the whole case. Nothing, for
instance, is more liable to confuse and to prevent you from coming to a
correct conclusion than wandering from one date to another without regard
to the chronological sequence in the history of an illness. And again, in
physical examination, nothing is so likely to lead you astray as wandering
from organ to organ without first completing the examination of each.

§ 6. Classiflcation of Diseases — ^Method of Procednre. — It has been cus-
tomary, and the practice is convenient, to classify diseases into two great

14 CLINICAL 'METHODS [ § 6

groups — Constitutional and Local. Local diseases are those in which the
principal, and perhaps the only, lesion is localised in one organ or situa-
tion, e.g,, facial neuralgia, ringworm. Constitutional diseases are those
in which the disease has manifestations of general distribution, e.gr., acute
rheumatism, typhoid fever, and pyaemia.

It is convenient for clinical purposes to preserve this division, but the rapid advance
of pathology has gradually transferred disorders from the " local " to the ** constitu-
tional " group. A large number of diseases formerly believed to be lesions of local
origin (such, for .nstance, as pneumonia, endocarditis, and peritonitis) are now known
to be due to some general morbid process, toxic or microbic, which, reaching the blood,
is carried by the circulation all over the body and causes a special local manifestation
in one situation.

From a pathological standpoint diseases are sometimes divided into two groups —
Oi^anic, those in which some anatomical change is found after death ; and Functional,
those in which no structural alteration is found. The anatomical or structural change
is spoken of as the '* lesion." The word *' functional " must not be regarded as
synonymous with " hysterical"

Now it so happens that local disorders are very often met with as com-
plications or effects of constitutional or general conditions ; and since in
clinical work we are engaged in tracing from effect to caiuie, we shall, in
the following chapters, take the local diseases which are manifested by a
lesion localised in some particular organ first, and the constitutional con-
ditions afterwards.

When a patient applies to us, if, as the result of our inquiries, we find he
is suffering from a symptom localised to some organ (e.gr., pain in the liver)
turn to the chapters relating to the diseases of the organ (one of the
Chapters IIL to XIV.).

If, on the other hand, he has no localised symptom, but complains of
malaise, feverishness, or a sense of " bodily illness," turn to the chapters
on constitutional diseases (Chapters XV. to XIX.).

CHAPTER II

THE FACIES, OR EXTERNAL APPEARANCE OF DISEASE a

In out scheme of case-taking it will be remembered that the first step in
physical examination was to observe the patient's general condition ; and
it will also be remembered how great was the importance of an adequate
inspection of the patient while he was telling us the story of his illness.

Some diseases can be identified almost at a glance, before the patient
opens his lips, such, for instance, as Chronic Alcoholism, some manifesta-
tions of Hereditary Syphilis, Graves' Disease, Cretinism, Myxoedema,
Facial Paralysis, and Hydrocephalus, when these conditions have passed
beyond the incipient stage. The existence of others can be very strongly
suspected, such as Rickets, Postnasal Adenoids (mouth-breathing children),
and Chronic Bronchitis with Dilated Right Heart.

But, apart from these, much may be learned from the first glance at a
patient — from his decubitus (the way he lies), from his attitude or gait (if
he be able to leave his bed), from the expression of his ^ace, the colour
of his skin, and from the general conformation of his body — without the
employment of any special methods of apparatus for diagnosis. It is to
be feared that as scientific methods become more and more perfect, these
means, which constitute one of the most useful and important aids to
diagnosis and prognosis to the experienced busy practitioner, are apt to
be neglected. But, on the other hand, students and young practitioners
had better not attempt " lightning diagnoses," or they will certainly fall
into the most serious errors. Some men, it is true, seem to be specially
gifted in this way ; but it is only by long experience and the possession of
special faculties that they can accomplish such feats.

It is a fundamental rule that your patient should face the light at all
medical interviews. Similarly your own chair should be in the shade, lest
the patient should read too readily what is passing through your mind.
It is surprising what important clues can be obtained by an intelligent
inspection of your patient, both as to his character and his disease.

The facies of disease may be summarised under three headings : (A) The
Physiognomy of Disease. (B) The Decubitus, Attitude, or Gait.
(C) Alterations in the General Conformation of the Body.

^ The Latin word facies signiiiea an appearance, form, or shape.

16 THE FACIE8 OF DISEASE [§J7,8

Hints to be derived from an inspection of the hands are given under
Diseases of the Extremities (Chapter XVII.). The various diseases will
be only mentioned here. The description and differentiation of the several
afiections referred to will be entered into more fully in the chapters which
follow.

(A) The Physiognomy in Disease.

An observant physician can obtain important clues to diagnosis by the
physiognomy — i.e., the aspect and expression of the patient's face — even
apart from the insight which can be gained by this means into his character.

§ ?• In Acute Diseases more can be learned from the position in which
the patient lies (i.e., his Decubitus, § 14) than from the physiognomy or
expression of his face. But it is worth remembering that the face assumes
an anxious expressioUy which is very characteristic in pericarditis, peri-
tonitis, and severe pneumonia, also during attacks of angina pectoris.
The supervention of actUe pericarditis in the course of rheumatic fever is
often unsuspected, as there may be no local symptoms ; but it may be
recognised by this anxious expression, the dilated nostrils, and the flush
upon the cheeks, which were (probably) at our last visit so pale. In acute
croupous pneumoniaj again, the appearance is very distinctive. The
flushed face, hot dry skin, widely dilating nostrils, the eruption of herpes
beside the mouth, and the profound disturbance of the pulse-respiration
ratio (1:2 instead of 1 : 4, which is the normal), form a picture which
greatly aids the recognition of the disease. The Fades Hippocratica — a
facies or appearance, of which the description has been handed down from
Hippocrates — is the forerunner of death from exhaustion, such, for in-
stance, as the final stage of cholera, and wasting disorders. The temples
are hollow, the eyes sunken, the eyelids slightly parted, the eyes glazed,
and the lower jaw droops. The Risus Sardonicus is a fixed grin, met with
typically in tetanus. The corners of the mouth, which twitch at intervals,
are drawn upwards as in laughter, and the features assume a fixed sarcastic
expression.

§8. A few Chronic Diseases may be enumerated in which the physi-
. ognomy is characteristic.

(i.) The aspect of a phthisical or tuberculous patient differs in the pre-
monitory and advanced stages, (a) Before any evidences can be detected
by physical examination of the chest, the patient has the appearance
which is loosely described by the laity as " delicate." The skin is fine
and soft, and the fresh, rosy colour of the cheeks is out of keeping with the
dark rings aroimd the sunken eyes. But it is by the deficient chest
measurements and sloping shoulders that the " strumous diathesis," as
this tendency or predisposition to tuberculosis is called, makes itself
especially manifest. The shoulders slope, and the transverse diameter is
deficient in proportion to the antero-posterior (see Chapter VI.). Some-
times such patients are plump and rosy ; nevertheless, they have a deficient
chest measurement, (b) When the disease is advanced, the phthisical

§ 9 ] SWELLING OF THE FACE AND NECK 17

patient often presents an appearance that enables the physician to hazard
a diagnosis almost without further investigation. The pale, emaciated
face, with sunken eyes, the circular crimson flush of hectic fever on the
cheeks, the wasted body, bathed from time to time in sweat, the hoarse
voice and easily-provoked dyspnoea, collectively form a picture which ifi
very characteristic.

(ii.) Chronic bronchitis with dilated right heart is another condition of
extremely common occurrence in the practitioner's daily practice, and
the picture these patients present is very characteristic. The florid
'* healthy " looking cheeks, the pulsating jugulars, in a person over forty
(more often of the female sex) is very typical.

(ill.) In chronic alcoholism there is a pufliness of the face and a congested
watery look about the eyes (" a blear-eyed look "). The eyelids are puffy,
80 that the person is described by sailors as having " an eye like a poached
egg." The cheeks and nose are often red, and dotted with stellate venous
capillaries. The belly is corpulent ; and on holding out the hands and
spreading the fingers, they are seen to be affected with fine small rhythmical
tremors. The whole picture is unmistakable, though the eyes alone will
tell the tale.

§9. SweUing ol the Face and neck, if associated with oedema of the
limbs and tnmk, may be part of a generalised dropsy. In the dropsy of
renal diseasCy on account of the looseness of the cellular tissues around
the eyelids, the swelling is most obvious in that situation. The pufliness of
the eyelids due to renal disease is, however, greater in the morning than
in the evening, and in this way may be distinguished from a similar con-
dition due to arsenical poisoning or whooping-cough. The dropsy of
cardiac disease is more diffuse.

A swollen, oedematous condition of the face, accompanied frequently by
a troublesome redness, coming on after meals, is a symptom for which
dyspeptic patients often seek advice. It also forms part of that trouble-
some condition urticaria factitiosa. A swelling of the face is also apt to
occur with different forms of erythema, and is generally worse after meals.
In chlorosis and severe ansemia the pallor of the skin may be associated
with some oedema.

Chronic cedema around the eydids must not be mistaken for myxoedema.
It is a not infrequent sequel to recurrent eczema, or repeated attacks of
er3rsipelas, in that situation. It is also met with in nervous or hysterical
conditions, and in vaso-motor derangements, when it is liable to transient
exacerl)ations.

(Edema confined to the head and neck is found in those rare cases where
there is pressure on the veins within the thorax, especially the superior
vena cava, as in cases of mediastinal tumour ; or with tumours within the
skur.

Myxcedema may often be recognised by a glance at the patient's face
^nd hands (Fig. 1). There is a solid oedema and pufliness of the face — the

18 TBE FACIES OF DISEASE [ !10

body and limbs being also affected — but it does not pit on pressure. The
vacant, stolid look, fiushed cheeks, '^scanty hair, and slow speech are
equally typical of this disorder. The hands are flat, coarse, and swollen
(see § 420). In acromegaly the jaws, lips and end of the nose are thickened
and enlaced {g 449).

§ 10. Tlie Complexion and colour of the face will repay careful insper^-
tion, for thereby the trained obser\-er will acquire some useful hinta. Thus,
the pallor of syphili.'f or tubercle, and other anceniic conditious, is often

He. 1.— UTXaDUA,— The patient »>• & man atiAd thirty, who nag Admitted Into tha PsddlnEton
IiiDrmuy la November, ISS7, pnwentlog all the luiul lymplunu of the dtieue. Ela tnove-
menla and laeuta] proctuea were eitremely alow ; average temperatuie »7-2 ; the quantity
ol area paated waa leu than halt tha normal. There wu a t«ndenry to liicinorrhagea (iwv
further partlcnlan In Hed. Soc. Proc., vol. xl.).

very striking. So also is the pallor, or rather sallowness, of aortic valvular
disease ; the dead white or waxen puffy appearance of parenchymatous
nephritis ; the greyish pallor of chronic interstitial nephritis ; the charac-
teristic yellowish hue of chlorosis ; the primrosf colour of that happily
much rarer condition, pernicious antemia.i The deep yellow to greenish-
yellow colour of jaundice ; the dull earthy look of malarial cachexia, cancer,

• It ie ODly by Iohr iMperience that one is enabled to distinguish these t«6neinentB

i H ] THE FACE IN DETAIL 10

and chronic abdominal disease ; and the purple (or cyanotic) appearance o{
the cheeks and lips in mitral and congenital heart disease, are still more
distinctive. A famt ydiow tinge with pallor occurs with old age, early
catarrhal jaundice, choUemia and severe ansamias. Dark rings around
the eyelids appear in states of fatigue ; they often indicate want of sleep,
or indigestion, and may be so pronounced in malarial conditions as to
resemble the ecehj'mosis of a bruise. Bronzing is seen with Addison's
disease, arsenical poisoning, htemochromatosis, and in half-castes.

Seborrhcea oleosa of the scalp gives rise to greaaineta of the face ; and
this, with the erythema which frequently accompanies it, produces an
appearance somewhat resembling a badly polished copper kettle. A
greasy complexion of this kind is
a great affliction to some young
and otherwise attractive women,
who might easily be rid of it by the
cure of the scalp lesion. A muddi/
sallow complexion may be associ-
ated with dyspepsia, when the lips
are usually dry.

g 11, The Face in Delail merit« a
little closer study, and, first, that
most eloquent portion of it, the eyes.

(i.) The eyes may be protuberant
as a whole (Froptosis), as in Graves'
disease, intra- ocular tumoor, or
tuemorrhage or thrombosis of the
cavernous sinus- In protuberance
due to acute blood diseases the
ophthalmoscopic appearance may
be normal. Protrusion of the eye-
balls is one of the most constant
symptoms of Oraves' disease. An

eauallv common ara of this dis- Fia.2,— EiopHiHAunoooiTKiioraves'DiiftMe).
^, . .. ° , , , From Byiom Brammll'a " Atlu of CllnlMl

order is a goitrous enlargement of uedtdne."
the thyroid gland, and therefore the

malady is also called Exophthalmic Goitre (see Fig. 2). The appearance
of protrusion may be caused by loss of intra-orbital fat. The eyeballs
may recede in paralysis of the cervical sympathetic, in wasting diseases,
collapse, and the diseases which lead to collapse. The pallor of aneemia
is seen in the conjunctivse, and in the sclerotic, or white of the eye, the
tinge of jaundice can often be detected when the yellow colour of the skin
is so slight as to escape detection. The sclerotic may be yellow also in
severe annmia and in old people ; it may be bluish in congenital heart
disease, and in the rheumatic diathesis. The " arcus senilis " is a white
ring of opacity in the cornea, just within its peripheral margin. It is

20 THE FACIES OF DISEASE [ | IS

usually believed to indicate senile degeneration of the arteries and other
tissues of the body, but I never found it so among the old people in the
Paddii^ton Workhouse and Infirmar}'. In adults vho are subjects of
hereditary syphilis, the comece may present struB, or the appearance of
ground glass (Fig. 3), due to interstitial keratitis. Alterations of the jAtfU
are dealt with elsewhere.

(ii.) The lifs may show the pallor of aneemia on the one band or the con-
gestion or cyanosis of cardiac disease on the other. The mouth is held
open when adenoids are present, in idiocy, cretinism, and certain paralyses.
Fissures and mucojia tubercles may indicate that syphilis ia in operation.
Stellate cicatrices around the lips are a record of previous or hereditary
syphilis. Dryness of the lips
occurs with fever and gastric
disturbance. The position and
movements of the mouth are
characteristic in facial and bulbar
paralysis, in the Landouzy-
Dejerine type of myopathy, and
in thetremorsof general paralysis
of the insane.

(iii.) The teeth may present
the evidences of pyorrhoea or of
hereditary syphilis, in which
disease, as Hutchinson has
pointed out, the permanent in-
cisors (that is to say, when the
child has reached the age of
seven) are characteristically
" P*f>S^<l " — '■^■' narrower at
the cutting edge, and notched

Fig. 3.— HebeDRaBT Stmius.— Showina thelnUr- (^" *'^ § l*'^)"

BtlU«lker«tlU«»ncl "pegged teeth "iJlHeredllary (iv.) Depression of the bridije

srphiUs. ,' , ' '^ .. , J ■ .

of the nose, if marked, is due

to chronic rhinitis in childhood, usually of syphilitic origin. In such cases
the nose is characteristically broad and flat, or small and " snub," like
a button, the opera-glass nose of Foumier. The end of the nose is
enlarged in acromegaly and myxtedema.

(v.) The eon lamy levesl disgnostia evidence of lupua erythem&toBDB, circulatory
disturbances, and the tophi of gout.

(vi.) Defective development ma; be i«cogniaed by " stigmata," such as epirjinthic
fold, liare-lip, oleft palate, occeesoiy auricles, and dermoid cysts.

§ 12. The Phyaiognomr of Childhood requires considerable experience to
appreciate it fully ; then it lends us mvaluable aid.

(i.) Congenital typkUis gives to an infant a very characteristic, pinched,
wan, or " senile " face. The complexion is ashy-grey, the skin is " drawn "
and it may be flaky or parchment-like. The eyes and cheeks are so hoHow

§18] VARIATION a IN THE FORM OF THE SKULL 21

that the nose seems unduly prominent, and thus gives to the infant the
appearance of a little wizened old man.

(ii.) When an infant is experiencing fain the face will sometimes give
a clue to its situation. Thus, a wrinkling of the forehead or frown is
indicative of pain in the head ; a drawing-up of the mouth at the comers,
producing marked naso-labial folds, points to severe abdominal pain ; a
dilatation of the nostrils and elevation of the eyebrows may suggest intra-
thoracic discomfort ; and in tabes mesenterica and other chronic wasting
diseases the face gradually assumes a fixed or contracted condition, in
which the angles of the mouth are depressed.

(iii.) Nothing is more characteristic than the listless and apathetic facies
of children suffering from the early stages of fever.

(iv.) MotUh'breathing children (due generally to postnasal adenoids),
have a very characteristic expression. The broad bridge of the nose and
open mouth give to them a vacant, stupid appearance, which sometimes
belies their intelligence, though sometimes they are, in fact, mentally
backward.

(v.) The fontaneUes afford information as to the general condition of a
child. A depressed fontanelle is an untoward sign in all acute illnesses of
childhood — e.g., the diarrhoea and vomiting of infancy. The fontanelle^
bulge in inflammation of the meninges, and this is a useful diagnostic
feature between true meningeal affections on the one hand, and fevers,
fx>ncho-pneumonia, and other diseases with cei*ebrdl symptoms on the
^ther. The fontanelles are tense and bulging in all diseases causing
increased intracranial pressure — e.g., cerebral tumour. Normally, the
anterior fontanelle should be closed between the ages of one and a half
and two years, and the posterior at birth. In rickets the former is late
in closing.

S 18. Variation! in the Form ot the Skoll aro met with in several complaints, and
chiefly in childran, b-Dcauso cases of marked deformity of the head seldom reach adult
life, except in the shelter of an asylum for the insane. The following variations are
noteworthy : —

(L) Aaymmtiry m^y bo congenital, due to a diffioult labour, or acquired in early
life from the continual nursing of the infant on one arm. The head is flattened on
the side it rests on A course of nursing on tho obhor arm will correct the deformity
in the most surprising way.

(ii). In hydrocephalua (§ 625) the head is large out of all proportion to tho face, and
the forehead overhangs the face.

(iiL) In rickets the skull is large and square, but the forehead rises straight up and
doei not overhang. There aro often bosses in tho frontal and piriotal regions.

(iv.) In hereditary ayphUis the bones around the anterior fontanelle are thickened,
and there are irregular areas of thickening and thinning (cranio-tabos), especially
behind the ears. The condition resembles that found in rickets, with which it not
infrequently ooeziBte.

(v.) In microcephaly the forehead is receding and the cranium very small. The
children are mentally defective. In scaphocephaly the head is elongated and its
lateral diameter diminished. Defective mental development may co-exist with other
** stigmata of degeneration/* such as high arched palate, accessory auricles, etc.

(vL) In adidts signs of infantile malformations may be found, and localised thicken-
ings may also be seen in osteitis deformans, leontiasis ossea, and after injury.

22 THE FACIE8 OF DISEASE [ § 14

(vii.) In acromegaly (§ 449) the lower jaw is enlarged and often the nose also. The
face is ovoid with the long transverse diameter below.

(viii.) In osteitis deformans (Paget's disease) the face is ovoid but with the long
transverse diameter above. The hands and feet are also big and clumsy, but the skin
is normal.

In various diieaief of the ner?oiu system the face presents a pathognomonic ex-
pression. Thus in Bell's or facial paralysis the face is distorted, and so also in that
rare condition facial hemiatrophy. The expression is vacant in idiocy, some hysterical
subjects, and early disseminated sclerosis. A smooth, expressionless appearance
(differing from the preceding in that there is a lack of mobility) is very characteristic
of paralysis agitans, and among rarer conditions, of double facial paralysis, the myo-
pathies affecting the face muscles, scleroderma, and Raynaud's disease (on acoount
of the scleroderma present). Bulbar paralysis gives a very characteristic, mournful,
or sullen appearance to the face. In this disease the orbicularis oris is paralysed, and
allows the lower lip to pout ; while the weakness of the zygomatici results in a drooping
of the comers of the mouth, such as wo usually associate with sorrow or suUenness
of temper. In a more advanced stage the saliva dribbles out of the mouth. Certain
spasms and tremors are recognised at a glance (§ 594).

(B) Decubitus (in Acute Conditions) and Attitude (in Chronic

Diseases).^

§14. Decnbiius signifies the position which a patient tends most con-
stantly to assume, and it often gives a valuable clue to the disease, more
especially in the diagnosis of Acute Diseases, and sometimes as to their
probable issue as well. For example :

(i.) Sitting up in bed, propped up with pillows, on account of inability to
breathe in other positions (orthopnoea), is characteristic of the extreme
breathlessness which occurs in advanced cardiac, pulmonary, or renal disease.

(ii.) Lying on one side is characteristic of considerable pleural efiusion or
pneumonia on that side, as in this position free play is given to the healthy
lung. When a phthisical patient always lies on one side, we may suspect
a cavity, bronchiectasis, or empyema of that side. A patient curls up on
one side in colic and in certain forms of meningitis.

(iii.) The dorsal decubitus — 1.6., lying on the back — is seen ingrave
illnesses attended by marked prostration, (a) In the '' typhoid state "
the limbs are stretched out and completely relaxed. The typhoid state,
so called from its occurrence in tjrphus and tjrphoid fevers, is a condition
of profound prostration, attended by unconsciousness or muttering
delirium, sordes on the teeth, and a dry, cracked tongue. (6) If the prostra-
tion be due to peritonitis, the legs are drawn up, so as to relax the abdo-
minal muscles ; and for the same reason the breathing is thoracic and the
abdomen is quite still. The greater flexion of one leg may give a clue as
to the side on which the trouble exists.

(iv.) Opisthotonos is an arching of the back which occurs in some con-
vulsive and spasmodic disorders. It may be so great that only the head
and heels touch the bed. It is met with in tetanus, hystero-epilepsy, and
strychnine poisoning.

^ The various characteristic gaits are described under Diseases of the Nervous
System.

116] THE ATTITUDE 23

(v.) Retraclvm of the head m cbaraoteristic in ceiebro-spinal and post-
basal meningitis. It is also met with in infants witb digestive disorders or
febrile states, in dyspncea due to laryngeal obstruction, and in rare cases
of cervical caries.

(vi.) Reslkaaness occurs in many disorders, acute and chronic, and is
generally a grave sign in the former — e.g., in acute pericarditis. Some-
times, as in children, it is an indica-
tion of severe pain. Carphatogy
(Kap^os = the clothes, kiytiv — to
pluck), or floccitatio, is the picking
at the bedclothes so obaracteristic
of the " typhoid state." The hands
seek after imaginary objects. StA-
aullv* tendinum is the muscular
twitching or tremor which occurs
-"Ifl^TEe same state. Both of these
imply extreme cerebral depression.
They are met with in the malignant
forms of the acute specific fevers,
and are of the gravest possible import.

§ IS. The Attitude which is involun-
tarily assumed by a patient suffering
from certain cluonic diseases, if be be
able to leave his bed, is very charac-
teristic. Thus :

(l) In paralysis agitans the bead,

neck, and thorax are bent forwards,

the arms are bent at the elbows, the

body moves stifSy " as if made of

glass," and the patient has t^e

characteristic " festination gait "

(Fig. 4). The disease is recognisable

at sight by the smooth, expressionless

face, fixity of gaze (always looking

forwards), the forward bending of the

body, tremors of the hands, and tbe _ „ . , „

, ' ' , ■ , ., ■■ . . . Fig- *.— The attitude typical of Paealtbib

short steps which the patient takes AoiIAHSiCroiaapluteicBstbrU.PuilRiclier.

as he shuffles along, (ii.) Tbe attitude

assumed by children sufiering from post-diphtheritic'paTali/sis is somewhat
similar to the preceding, and is so characteristic that one cttn often detect
the disease as the patient enters the room. Tbe bead hangs forward from
weakness of the neck muscles, and tbe " flabbiness " of all the move-
ments is peculiar, (iii.) The rigidity of the spine in rheumatoid arthritis,
osteo-arthritis, and spinal caries, gives a stifiness and awkwardness to all
the movements which is very noticeable.

24 THE FACIB8 OF DI8BASB t } 16

(iv.) Duchenue'tt yteado-hyperirophic pandgait (Fig- 5) U » oompu&tjvoljt ram con-
dition, but the »rohing forwards of the baok. prominenoa of the buttooks, Bcapule.
and calvM, and inability to rise from a iccumbent postnis without the aid of the
hands, ara qnita pathognomonic.

g 16. Under this heading we note (a) whether the patient exhibits any

lose of flesh {Emaciation, in^) ; (b) whether he piesente any increase in

volume (General Enlaroehbnt, § 17) ; or (c) whether he presents any

DEFORHiry or Dwarfism (§ 19).

Here we shall meet with several important
diseases affecting the skeleton and general
growth of the individual, especially Hered-
itary Syphilis. The various causes of such
alterations will only be mentioned here. They
will be described and difierentiated under
the Diseases of Eztremitiea, and elsewhere.

Variations iw Health. — The terms
" Emaciation " and " General Enlargement
of the Body " are only relative. The
healthy man should have an elastic skin,
firm muscles, and a slight amount of sub-
cutaneous fat ; but individtial variaHona are
BO great that no definite standard can be set
up as normal. Health in the wiry, nervous
man is consistent with a spareness that
would indicate disease in his stouter and
more phlegmatic brother. The same holds
true with regard to age. A child has an
amount of fatty covering that would be
abnormal in adolescence ; an old man has
atrophy of the soft parts and prominence of
the bones which in the middle-aged man
could only accompany serious disease. The
question of build is very largely one of
hereiUi/. Stout parents generally have
children who t«nd to become stout, and trice
vena.

(a) Emaciation is necessarily attended by
more or less weakoess, and the subject is dealt
with under General Debility (Chapter XVI.).

Flj. K,— PsEDDO-EVFRRTEOPHia PARiLYSiBot Duchanns-— Thl» patlBttt 1* a boy, atied nine yetis-
The lUiutratlOD ■haws w«J the two moat charactsriatlc teaturca of Uis dknua— uunely,
*™ Ba'UBemDDt ol the calves aail battooka, and tha (trching Inwarda ol the back (lotdtMls).
The dltBUe la often combined, a* hen, with true mDMUlar atiophy In oUnr parta— «.f ., the
■hoolder girdle— «nd ther«rore the scapula project. The cbUd abo eihlblted the tyi^cal
mumer of EBttloji up from the prone pualtloa. Tlie child seemed Darmal udUI lie bejan to
walk at two yean, wheo It wii noticed he " lilted Itli leiv too high."

$S 17.18] GENERAL ENLARQEMENT— OBESITY 25

The chief causes of debility with emaciation are as follows : Malignant
disease, digestive disorders and privation, diabetes, various nervous dis-
orders, chronic Bright's disease, syphilis, tubercle, and pancreatic diseases ;
and in children, tabes mesenterica, defective feeding, diarrhoea, and
hereditary syphilis.

In advanced life the first cause which occurs to our minds, if the patient
has lost flesh, is cancer ; in middle age, diabetes ; and in younj adults,
tuberculosis. In tuberculosis of the lungs or elsewhere, emaciation may
occur before any physical signs can be detected ; indeed, loss of flesh
which is accompanied by an intermitting pyrexia generally means latent
tuberculosis. In infancy the two most common causes of acute or rajyid
wasting are Defective Feeding and Gastro-Intestinal Catarrh. The two
most common causes of slow, progressive, or chronic wasting in infants are
tuberculosis of the intestine and mesenteric glands, and Hereditary
Syphilis (§§417 and 404). In hereditary syphilis the child may be born
quite healthy in appearance, but often soon begins to waste, the face
presenting a wizened " old man " aspect.

§ 17. General Eniargdment of the body is much less often met with than
diminution. It occurs in Obesity y Generalised Dropsy (see §§ 9 and 21),
Myxcedema (see § 9, and General Debility, § 419), and Acromegaly,^ It is
probable that the giants of old were specimens of acromegaly. These
affections will be described and differentiated elsewhere, but since the
treatment of obesity has unfortunately been allowed to get into the hands
of charlatans and patent-medicine vendors, it will be well to add a few
remarks on the causes and treatment of that condition.

§ 18. Obesity ia veiy largely a question of heredity, and no amount of dieting will
make any difference in some people. In others it is an indication of luxurious or
sedentary living, or of indulgence in alcohol. Women frequently become obese just
about the menopause. Sometimes it is found in chronic cerebral disease, such as
idiocy or tumour, and, more rarely, in tumours of the adrenal bodies, associated with
sexual precocity.^ The pathological causes of obesity come under two headings :
(L) excessive intake of those food-stuffs known to produce fat ; and (ii.) deficient
oxygenation. It is probably due to the latter cause that persons with persistent low
tension are apt to become fat. Both causes may be in operation. Successful treat-
ment must therefore depend either upon diminution of intake or increase of
oxygenation.

Tbeatmxnt. — Our first duty when consulted about such cases is to examine every
organ in the body, especially the heart, lungs, and liver, because excess of subcutaneous
fat is often attended by a similar deposit of subpericardial fat ; and, if due to alcohol,
by fatty degeneration of both heart and liver. Chronic bronchitis and emphysema
are also frequently followed by obesity from deficient oxygenation. If no serious
lesion be present, there are at least five methods of reduction : (1) To limit the amount
of fluid taken with meals ; (2) Banting*s system consists in excluding all fats, sugars,
and starches from the diet, green vegetables and lean meat alone being allowed ;
(3) Ebstein's system only excludes all sugars and other carbohydrates ; (4) OerteFs
system is the most complete, and consists in (i.) slowly climbing mountains for several
hours daily, inspiring with one step and expiring with the next ; (ii.) food mainly

^ [ have also met with general enlargement of the extremities in certain rare cases
presenting vaso-motor symptoms.
* Guthrie and £mery» CUn. Soc. Trans.. 1907.

26 THE FACIB8 OF 'DISEASE [ § 19

nitrogenous, with small quantities of fats and starches ; and (iii.) the fluid limited to
1} pints in twenty-four hours (see Chapter III., { 51). (5) Some eckses of obesity may
be successfully reduced by limiting the food entirely to one pound of lean meat or fish a
day, divided into four meals, taken without fluid ; between meals the patient should
drhik as much hot water as possible by constantly sipping it If the patient will co-
operate, this method is very successful,^ but the diet is a Spartan one. Thyroid or
strychnine, either separately or together, are also of value in obesity, especially in
tiiose oases occurring about the menopause when the apparent obesity is often due in
reality to a myxoBdematous deposit.

Adiposis Dolorosa ^ is a rare variety of obesity described by Dercum. It is character-
ised by the local deposition of fat in the form of tender adipose tumours. The
condition spreads and becomes more general, the hands, feet, and face escaping.
Pains, both constant and paroxysmal, occur in various situations, associated with
great muscular weakness and areas of partial loss of sensation. Professor Stockman
contends that the condition is common, and is a chronic subcutaneous fibrosis, which
in Dercum*8 cases was accompanied by much subcutaneous fat. The fibrosis is
a chronic inflammatory change secondary to acute or chronic infections. It is curable
by massage, and plenty of daily fresh-air exercise.^

§ 19. Dwarflim, or diminished stature, may arise from any cause which affects the
growth of the bones of the trunk or limbs, whether local or constitutional. The
commonest causes of a stunted condition of the body, n order of frequency, are :

(i.) Bickets, — In this disease there is curving of the long bones, together with altered
epiphyseal growth. This results in " bandy legs," ^* knock-knee," and other familiar
deformities (see Chapter XVII., § 447).

(ii.) Hereditary Syphilis, the means of recognising which are fully given in
CTuipter XVI., f 404.

(iii.) Curvature of the Spine, which may take three forms : (i.) kyphosis {i.e., the
convexity projecting backwards), usually due to tuberculous or other disease of the
vertebrse, or to laxity of the ligaments, as in rickets. The latter disappears when the
child is held up by the shoulders, (ii.) Lordosis {i.e., a forward projection), usually
compensatory, or the result of muscular weakness ; and (iii.) scoliosis (a lateral curve).
All these may diminish the stature, but they differ considerably in importance. A
certain amount of scoliosis is normal to nearly everyone, and the kjrphosis of muscular
weakness is common enough in old age, as a consequence of which our stature becomes
slightly less in advancing years. It is the angular kyphosis which is so serious, as
indicating organic diseases of the bodies of the vertebrae.

(iv.) Cretinism (§ 138) is a peculiar stunting of the growth which is endemic among
children in certain districts. The appearance is so distinctive that typical cases can
be recognised at a distance (Fig. 6). The face is broad and flat, and joined almost
without a neck to the body. The skin and hair are coarse, the hands broad and
stumpy, the stature stunted, for even when twenty years of age a cretin may be only
3 i'eet high. It is due to a perverted or diminished action of the thyroid gland, and
recovery usually results and is maintained while thjrroid extract is being given (Fig. 7).

(v.) Mongolism is a condition of defective development met with chiefly in the
last children of long families. It is differentiated from cretinism by the fine hair,
clear complexion, broad head, and liveliness of manner. The name is derived from
their resemblance to the Mongolian races. The eyes are oval and slant upwards at
the outer angle, the little finger tends to curve inwards ; they often squint, and are
the subjects of various ** stigmata '* of *' degeneration."

(vi.) Achondroplasia, — A rare condition somewhat resembling, and formerly con-
fused with. Rickets (see § 449).

(vii.) Osteomalacia, when this disease involves the spine (§ 449).

(viii.) Infantilism is due to a loss or perversion of internal secretions, the usual
changes, both sexual and physical, which normally occur at puberty failing to take

^ A case is published in the Lancet, 1893, vol. ii., p. 133.

' Dercum, Iniemat, Joum, Med. Set., 1892, p. 521 ; and Brit. Med. Joum., 1889»
vol. ii., p. 1553.
3 Brit. Med. Joum., 1911, vol. I, p. 352.

i II ] DWARFISM 21

place, and the patient retaining the stature, featnces, and voice, and often the mental
pn>cliTitie«, of a child. In oases with pancreatio insufficiency diarrhcea ie pieeent
These forms of iofaiitiligia cnn be treated with good roeulta bj thyroid and panoteatic
oxtnwtB. Under the name progeria Haatings Gilford has described a condition in
which infantilism is associated with premature dec&j, the appearance, attitude, and
state of nutrition of the dwarf beooming senile, and degenerative ohangea occaiting
in the vessels and viscera. A cachectic type of infantilism is described in which the
development is arrested owing to chronic infection such aa tuberculosis, syphilid and
c«rdiac disease, or drags such as alcohol, tobacco, lead, mercury, or morphia.

Kg. S. — Gate ol CftniKlSii under the care of W. Rushtoa Parker.— The child, aged aix, preseatel
the duTMterliUc Mpect ol a cretin— vli., aunkeu nose, ■wallen mooth, gmBll eyee widely
apart, coane hair, and stumpy Umba. Fig. T iliaws Um urns child alter ali moottu' treat-
mgnt vlUi thytoid gland (S giaini dally).

(iz.) In addition to the foiegolog there aie certaui ran conditions, of which the
celebrated Tom Thamb and his wife, and the race of pigmies of Africa met with by
Sir H. H. Stanley' and others, are examples, in which the skeleton and the organs aie
diminished in size, but theii proportions maintained. Such caaea, however, seem to be
functionally normal in every respect-
Some of the diseases above refened to bebng so distinctly to tbs domain oE suigery
that reference must be made to other works for their differentiation. Others will be
deMribed under IHseases of the Extremities.

' F. C. tjhrubeall, Lajiat, vol. i., 1003.

CHAPTER III

DISEASES OF THE HEART AND PERICARDIUM

There are three noteworthy facts in connection with the diseases of the

circulatory system. First, the left side of the heart is stronger and

much more prone to disease than the right ; secondly, the arteries are, in a

corresponding manner, much thicker and more often diseased than the

veins ; and thirdly, heredity plays a very prominent part in chronic

disorders of the heart and arteries.

The saying of Bjomson that *' herodity is a condition, not a destiny," ^ applies hero ;
for although its application is chiefly ethical, it may be employed in a physical sense
also. Careful living may do much to counteract the hereditary tendency to early
death from chronic cardio-vascular disease.

Following out the plan adopted in this work, we shall consider : —
First, the Symptoms which lead us to infer the presence of cardiac

disease ;

Secondly, the Physical Examination of the patient ; and

Thirdly, the Differentiation of the Various Diseases which affect

the heart and pericardium, their diagnosis, prognosis, and treatment.

PART A. SYMPTOMATOLOGY.

The general symptoms {e.g.y breathlessness, dropsy, etc.) of cardiac
disease, as distinct from the local signs referable to the heart, should be
studied very carefully, inasmuch as the gravity of any given case depends
not so much on the local signs present as on the general condition of the
patient.

The Three Cardinal Symptoms of diseases of the heart and peri-
cardium are Breathlessness, Dropsy* and Cyanosis. To these may be
added Palpitation^ PrsBCordial Pain» Syncope, sometimes Coagli» and in
acute affections, Pyrexia and its concomitant symptoms. Sadden Death
is more frequent in disorders of the heart than in disease of any other
viscus, and it is sometimes unattended by any previous manifestation of
heart disease.

§ 20. BreathlessnesSy or Dyspnoea, is a constant symptom in all diseases
in which the heart is unequal to the work demanded of it. Breathlessness

1 " The Heritage of the Kurte,"

§ 20 ] BREATHLES8NES8 29

may be present without cardiac disease ; but it may be affirmed that no
serious affection of the Cardiac Wall can exist without some degree of
breathlessness. It may be only on exertion, such as walking up a few
stairs, but it can always be elicited in some degree. The slightest degree
of dyspnoea may be detected by observing that the scaleni and lower
edges of the stemo- mastoids are brought into play at the end of
inspiration.

Severe disease of the Valves of the heart may, however, exist for many
years — provided the obstruction so caused is adequately compensated for
by increased growth in its muscular wall — without the patient having any
noteworthy symptoms, or even being aware of i(3 existence, until the
cardiac wall begins to degenerate and its cavity to dilate. Then, as time
goes on, breathlessness is sure to appear, and it is for this s^Tiipt^m that you
are generally consulted in heart cases. In the later stages it becomes so
pronounced that the patient is unable to breathe when lying down, and
night after night is passed sitting upright in a chair, or, at best, propped
up with pillows in bed. This degree of breathlessness is known as
orthopnoea.^ Towards the end, in a certain number of cases, a larger
proportion in my experience than is generally supposed, some degree ol
Cheyne- Stokes respiration may be observed.

Causes of Breathlessness (Dyspn(ea) . — Difficult breathing may arise
in five different groups of disorders. ^

1. Caidiac Disease. — The dyspnoea of heart disease has no intrinsic
features which distinguish it from that due to other causes, except that
it is apt in some cases to be paroxysmal. There is, however, usually a
history, or evidence, of some of the other symptoms of cardiac disorder.
In cardiac valvular disease the amount of breathlessness present and the
distance a patient can walk without producing it are, of all symptoms,
the most valuable indications as to the amount of inadequacy of the
cardiac muscle (cardiac failure) present in any particular case.

2. Embarrassment of the Heart by Neighbouring Structures, such as
a dilated stomach, ascites, mediastinal tumours, or obesity. Murchison
used to teach that dyspnoea and nearly all the symptoms of cardiac disease
(excepting cyanosis) may be produced by dyspepsia without any structural
disease of the heart.

3. Laryngeal or Tracheal Obstruction.

4. Pulmonary Disease, of which emphysema is the most conmion.

5. Toxic or Hsemic Conditions, the most frequent of which is certainly
anaemia. Deficient aeration and other poisonous conditions of the blood,
such as uraemia (chronic Bright's disease), diabetes, and all pyrexial states,
may be attended by dyspnoea, caused in this way.

^ This word implies veiy urgent dyspncBa— ^p^os, Greek, erect
3 This does not include l^e dyspnoea associated with vaso-motor spasm or with
yaeo-motOT paresis and states of low arterial tension, such as may be met with in
great prostration or bodily fatigue. This kind of dyspnoea, I have observed, has for its
chief feature a sighing character of the [respiration, |and long-drawn sighs occur eveiy
lew seconds.

30 DISEASES OF THE HEART AND PERICARDIUM [ §80a

Causes of Breathlessness which are ajd to be overlooked, — ^The differentiation of the
various forms of cardiac disease will be given in the following pages ; but, supposing
a patient over thirty-five or forty, who complains of breathlessness, presents no
definite signs of cardiac or pulmonary disease, nor any evidences of dyspepsia or
anaemia, then there are certain conditions which should be suspected :

1. Oardiao Enfeeblement or Fatty Degeneratioii, in which case the sounds and impulse
would be very feeble, and the other signs mentioned in § 62 should be present.

2. Arterial Sclerosis, in which case the radials would be hard and cord-like, but
smooth, unless atheroma were also present, and the arterial tension high (excepting in
the very last stage of the disease). Here, also, there would be giddiness, especially
on assuming the erect posture, and the other symptoms mentioned in § 67.

3. Aortic Stenosis, the murmur of which is sometimes very^difficult to^detect,
especially when attended by cardiac enfeeblem^it. ^

4. Deep-seated Aneurysm of the Aorta and other Intrathoracic Tamonrs may
give rise to the breathlessness and general symptoms of heart disease without thu
physical signs. In such cases tho dyspnoea may be paroxysmal.

5. Coronary Obstruction (i.e., diminution of the calibre of the coronary arteries by
atheroma, calcification, or other disease). In this obscure condition the patient
probably complains also of " dizziness in the head '" on suddenly assuming the erect
position, from the incapacity of the heart to pump the blood to the head. But this
condition can never be more than suspected during life.

In a patient under thirty-five or forty the three following causes of Unexplained
Breathlessness may be suspected :

6. Cardiac Syphilis may be imattended by any signs or symptoms, excepting breath-
lessness (§ 41). Happily the condition is very rare.

7. Adherent Pericardium, also, is often unattended by any physical signs ( § 38c).

8. Latent Polmonary Disease, and especially latent pulmonary tuberculosis, should
always be suspected in cases of breathlessness without obvious cause.

9. When severe dyspnoea sets in suddenly in the course of cardiac or Acute Renal
Disease, or during an attack of scarlatina^ the chest should always be carefully
examined, because double hydrothorax may set in rapidly without any general dropsy
or other warning symptom, as in a case mentioned by Osier, and a similar one which I
have had the opportunity of observing.

10. Disease of the costo-chondral or vertebral joints, which is known by pain on
pressure over the joints.

§ 20a. Paroxysmal Dyspncsa is that form of dyspnoea which occurs in attacks from
time to time. It is apt, as above mentioned, to occur in some cases of cardiac disease,
especially in the last stages of aortic regurgitation, and in any given case our attention
should first be directed to the heart. But there are several other conditions which
one would suspect in a patient in whom the chief or only symptom consists of paroxysms
of breathlessness.

1. Aneubysm and other Intrathoracic Tumours may give rise to paroxysmal
dyspnoea before other signs can be made out.

2. In Asthma, laryngismus stridulus, and whooping-cough, the attacks of breath-
lessness are typically paroxysmal.

3. Paroxysms of dyspnoea occurring at night are often one of the first symptoms of
Chbonio Bsight*s Disease, and are spoken of by the patient as asthma.

4. Neurotic DYSPN(EA.^-Some neurotic patients are liable to attacks or paroxysms
of panting respiration, resembling the panting of fear. It usually ceases when the
patient converses with you, and is, of course, unattended by any signs in the
lungs.

5. LiNOUAL Varix — I.e., a varicose condition of the veins at the root of the tongue —
may give rise to severe paroxysms of dyspnoea.^

6. Foreign Bodies in the trachea and retropharyngeal abscess in children, and
polypi or papillomata of the larynx in adults, give rise to paroxysms of dyspnoea.

^ A case of paroxysmal dyspnoea, cured by the removal of a lingual varix, is pub-
lished by M. P. Mayo Collier in the West Lond. Med. Chir. Soc. Trans., 1897, p. 206.

^att.tl^ nHETNE-STOKES RESPIRATION— DROPSY 31

7. Saddon dyapiKBa. ooming on daring vomiting, ia the main indiofttian of thst
nre accident, Ruptdrb of tbb <Esofb*git9. This dy apnoeft Ib due to pnenmothomT,
and bj promptly opening tbe thorftz on th&t iide the patient's life might be eaved.^

6. Enlargement of tiie Ththcs Gi-and in the condition known as Lvuphitish.
or Btatiu lymphaticus. in which there is gonoral hyporplaaia of lymphatic Btructnre.
Hseociated with a persistent thymus, may cause paroxysmal dyspncea, to which Ilio
name " thymic asthma " has been given (} 20).

t>. The laryngeal crisBs of tabes dorsalis may t«ke the form of paroxysmal dyapncea.

§ sob. Oberns-Stokea Bespiratlcni (so called after its lirat obeerveis) consista, in its
typical form, of a setiaa of eight or ten rapid inspirations gradually incieaeing ui depth
and rapidity, and then dying gradually away, each series being separated by a pause
of five to thirty seconds (the stage of apncea), in which there is hardly any respiratory
movement (Fig. S).

In a modified form, without the apncea pause, Cheyne-Slokcs breathing is by no
moans infrequent. It seems to indicate a want of harmony between the caidiac and
the VBSO-mot«r regulator mechaniHia. It is usually a serious symptom, and appeared
in the groat majority of those of my cardiac patients in the infirmary who were closely
observed totmriU the end of lift. It has less significance at the extremes of life, for it
may be olwerved during sleep in normal infants, and is compatible with a hale old age.
Another (xception to Uie unfavoumbln import of Chcync-StokeB breathing occurnd

Fig. fl. — CuEVNE-STOKK RespikaTiON. — Besplritory tracing a[ CheyDe-.Stukei breathing, for
■rhich (he author Is Indebted to Dr. C. O. Hawthorne, who took (tie trsdng from a cue of
cerBbral embolism mider his care In the Western InArmary, Olasgow.

under my notice in the case of a focal lesion of the pons, producing crossed hemiplegia,
in which it per8ist«d with only occasional intermissions during the last nx months of
the patient's life. Its principal catue* are as folbws :

1. Carduo D19BASB, whlch is certainly its commonest cause.

2. Ubxmia.

3. Apoplexv.

4. TuBBHcuLous Mbninoitis, and other states of cerebral congestion or com-
pression.

5. AsTKRUi. ScLBBOSis (used in its widest sense).

6. 8CH3TROKK.

Thus it will be seen that the three pathological conditions in which it is apt to
ocour are : States of cardiac failure ; states of cerebral congestion ; and toxio blood
conditions. ' - ,

§ 21. Dropsy is a chronic efEusion of fluid into the subcutaneons
tissue (when it is known as anasarca or cedema) or into the serous cavity
(as in hydrothorax, hydropericardium, ascites). The former. Anasarca,
is the variety of dropsy we are now concerned with, for It ia a very constant
feature of some forms of cardiac disease. General anasarca has to be
difierentiated from myxcedema, in which the swelling is harder, aod doea

' A few cases of this accident have been recorded. If it were recognised, the thorax
might |be opened without fear on the side of the 'pneumothorax, and the cesophagus
■titched. Bee DiscnsBJon at Roy. Med. Cliir. Soo. in spring of 1900.

32 DISEASES OF THE HEART AND PERICARDIUM [ § 21

not pit on pressure. It is best to apply the pressure over a bone, such as
the lower end of tibia on its inner aspect.

Causes, — The causes of localised dropsies are given in Diseases of the
Extremities (§ 425). There are three varieties of general anasarca, which
differ from each other both pathologically in their origin, and clinically in
the course which they pursue.

1. Cardiac Dropay (1) starts, and throughout the case predominates, in
the most dependent farts, that is to say, in the legs if the patient has been
walking about, or in the back if he has been lying in bed. On inquiry,
the patient may complain that the ankles swell towards evening around
the top of the boot. (2) Other signs and symptoms of cardiac enfeeble-
ment or dilatation are present ; and perhaps those of valvular disease as
well. (3) In the history of the case dyspnfpa will have f receded the
dropsy.

Dropsy does not occur with equal frequency in all foims of cardiac
valvular disease. It is common in disease of the mitral valves, but rare
in aortic disease, at any rate until quite the end. The dropsy which com-
plicates pulmonary disease has the same features as cardiac dropsy, because
it is the resulting cardiac dilatation which prcduces the dropsy.

2. Hepatic Dropsy (1) always begins and predominates in the abdomen
(ascites), although the legs may swell subsequently by reason of the
pressure of the fluid on the veins within the abdominal cavity. (2) There
may be also enlargement or other signs of the liver affection which has
given rise to the condition ; and if these be absent some other cause of
obstruction to the portal vein should be sought (Chapter XII.). (3) The
dyspnoea will \iQ,vQ followed the abdominal enlargement.

3. Renal Dropey is (1) general in its distribution from the beginning,
occurring in the legs and eyelids at the same time ; though it is probable
that the oedema round the eyes on rising in the morning first attracts
the attention of the patient or his friends. (2) Examination of the urine
leveals the features of renal disease (Chapter XIII.). (3) The patient
presents a characteristic pale or waxy appearance.

In some cases of general anasarca associated with albuminuria, the
question arises whether the dropsy is of renal or cardiac origin. This may
sometimes be answered by finding the liver enlarged, for this is a natural
sequence of cardiac valvular disease, but not of renal disease.

Prognosis, — The dropsy of cardiac disease is probably due to the back-
ward pressure within the veins, and its occurrence is therefore an indication
and a measure of the amount of obstruction to the circulation on the
right side of the heart.

The treatment of all forms of dropsy should be directed to the removal
of the cause. But even if this be not removable, the dropsy may frequently
be alleviated. The limbs should always be rested, raised to the same
level as the body, and kept warm. The additional support of a well-
adjusted flannel or stocking bandage is a great comfort to the patient, and
helps to prevent further effusion. Diuretics and diaphoretics should b^

§ 82 ] DROPS Y--PALPITATION 33

employed. These failing, we may (a) employ Southey's trocars, the
patient being wrapped in blankets and the fluid allowed to slowly drain
away ; or (h) make punctures in the skin of the limb with a small two-edged
scalpel. Six or eight punctures are sufficient, the positions of the veins
being avoided. Dropsical limbs have a tendency to the development of
eczema, erythema, cellulitis, and epidemic exfoliative dermatitis, so that
strict asepsis should be observed in these procedures.

Obscurh Causes of GsNisaAL Anasabca. — If, in a patient who complains of
dropsy, no ma^ed evidences of cardiac, renal, or hepatic disease are discoverable,
the following causes may be auspecUd :

1. Amemia is not infrequently attended by some swelling of the ankien at the end
of the day. This may appear quite early in chlorosis, but is rare in pernicious annmia.
Swelling of the feet and ankles may be present in the last stages of many exhausting
diseases, such as phthisiB, in septic states, and in cases of insufficient nutrition and
old age. Other d^ective blood conditions, such as leukemia, may also be accompanied
by dropsy.

2. In Fatty Heart anasarca is not a prominent symptom, but a slight degree is
frequently present.

3. Among the less frequent causes of dropsy in this country are Beri-Beri (§ 462) and
Epidemio Dropsy. In Beri-Beri there are symptoms of peripheral neuritis. Epidemic
dropsy is an acute infectious disease met with in the tropics, with dropsy but no
albuminuria.

4. General oedema, without urinary changes, following a gastro-intestinal upset,
has occurred in young children. Some have been cured by hypodermic injections
of adrenalin ; other cases have been fataL Milroy described a hereditary oedema in
which a solid oedema of the legs existed from birth, unattended by danger to life.

§ 22. Palpitation is the sensation of *' fluttering in the chest " experi-
enced by a person when he is conscious of the beating of his heart. It
arises under two sets of conditions It is said to be Symptomatio when
a cause can be assigned to it, such as heart disease, flatulent dyspepsia,
anffimia or intrathoracic tumour. It is said to be Idiopathic when no
organic cause can be discovered to account for the symptom (compare also
Paroxysmal Tachycardia, § 40).

Symptomatic Palpitation may arise from (a) causes referable to the
heart itself (causes 1 to 3) ; or (b) morbid conditions outside the heart
(causes 4 to 9).

1. Most Stmotnral Diseases of the Heart, especially such as are attended
by rapidity and irregularity of its rhythm, are attended by palpitation.
When patients consult us for this sjmiptom, we should therefore first make
a thorough examination of the heart and pericardium.

2. Palpitation is also the leading indication of the firritaUe Heart, in
which there may be no discoverable structural disease. Irritable heart
is found in young men who have overtaxed their strength in athletics or
military work, and occasionally in young women. Palpitation is its most
obvious symptom, with a very quick pulse, or one which easily becomes
rapidy and sometimes with high arterial tension. Breathlessness, sleepless-
ness, incapacity for prolonged exertion, and nervousness, often accompany
the palpitation. Hypertrophy is a common result; and unless rest be
ordered the heart will become dilated. Complete rest is the chief indication

§«B] DSOFST—PALPITATIOX J3

employed. These failing, we may (a) employ Sonrtiev-'s trocars, the
patient being wrapped in blankets and the fluid allowipd to sloiriy dnin
away ; or (6) make punctures in the sldn of the limb with a small two-ed^ed
scalpel. Six or eight punctures are sofficient, tiie pesitioos of the v^ns
being avoided. Dropsical limbs have a tendency to tbe dereh^Nneat of
eczema, erythema, cellulitis, and epidemic ezfoUatire dermatitit, so thai
strict asepBis should be obaerred in these procedaies.

I CAussa ov GEixaAi. Axasaxca. — If, in a pMient who comflama of
dropsy, no maHcod evideiiMs of Midiac, noal, or twpMJt^ iliwi are diwoivnUr,
the following caosen msj be nupteUd :

1. AniMBia is not iofreqneatlj att<aded bj sonw ivcUing of tha anklet ai tbe ^hI
of tha day. Thia may appear quite eaily in cUonMu, but is nta in pwniirio— an ■■la
Swelling of the feet and anUee may be ptMent in tlie laat rtagea of aaiiy exhanttiiig
diaoaoos, saoh aa phthisis, in septic states, and in ossrs of inmilficinit niitntiaa aod
oldaga. Other defective IJood cooditions, such aa kmkKmia, may abo be acoompaiuNl
by dropay.

2. la Fat^ Hsart anaearca is not a pcDmioMtt symptom, but a sl^tf ilaKreF is
freqaeatly priwont.

3. Among the lesB freqnent oanses of dropayin this eoimtryBieBwi-BMi(|MX)aad
■sUeiniB Diopar. In Beri-Bwi iiien are symptoma of psnpbenl nearitB. EpidBBk'
dropi? is an acute infeotioos disease met with in the tropic*, with dtopey bat no

4. GensTsl cedema, withont niinaiy chaogea, following a gaatro-intrstioal apse*.
baa ooeamd in yonng childmn. Some have bem cored by hypoderBue injeetioot
of adrenalin ; other cases have been fataL Milniy Jeaiiibud a heiedilaiy inliiiaa id
which a aolid cedema of the legs existed from birth, nnatteadcd hy danger to lifp.

§ 22. PalldUtion is the sensation of " fluttering in the chest " experi-
enced by a petBon when he is conscious of the beating of his heart. It
arises under two sets of conditions It is said to be Symptomatic when
a canse can be assigned to it, such as heart disease, flatolent dyspepsia,
antnnia or intrathoracic tumour. It is said to be Idiopathic when no
organic cause can be discovered to account for the svroptom (compare also
Faroxyanial Tachycardia, } 40).

Stmptomatio Palpitation may arise from (a) causes referable to the
heart itseU (causes I to 3) ; or (fr) morbid condirions outside the heart
(caoses 4 to 9).

I. Most Stnwttml noonico &t ttw Heart, especiaUy such as are attended
by rapidity and irregularity of its rhythm, are attended by {
When patients consult us for this symptom, we dtould therefore first n
a thorough examination of the heart and pericardium.

34 DI8EA8E8 OF THE HEART AND PERICARDIUM [§28

for treatment, and is generally successful. Irritable heart is, in my belief,
in some cases a sjonptom of neurasthenia (^.t;.).

3. Various Nervous CaoMS, such as fright, fear, or other emotion,
especially after an exhausting illness, give rise to palpitation (compare
Paroxysmal Tachycardia, § 40).

4. In Aii»iiiia the palpitation is a freqaent and often distressing feature.

5. In Dyipeptia palpitation is very often present. In such oases it frequently
occurs at night, especially after taking a heavy meal. It may, in these circumstances,
be acoobtipanied by' morbid dreads— c.^r.. of impending death — by breathlessness,
cardiac pain, and by other cardiac symptoms.

6. Certain Looal Oonditioni, such as thoracic or abdominal tumour, or dilated
stomach, which hamper the heart's action, may produce palpitation, although the
heart be healthy.

7. The excessive use of Certain Dmgi or Articles of Diet, notably tobacco, tea,
coffee, and alcohol.

8. In 0raves' Difease (exophthalmic goitre) violent palpitation and greatly increased
rate of the heart are prominent features. In quite a number of my cases this and
the other nervous symptoms of the disorder had existed for many months, or years,
before the two diagnostic features — thyroid enlargement and exophthalmos — became
obvious. Graves* disease should always bo suspected in cases of persistent palpitation
for which no cause can be made out.

9. In Hyitsrioal subjects palpitation is a symptom often complained of, and
occasionally it takes the form of a definite and somewhat alarming attack (see a case,
§40).

§ 28. Pain in the Chest is not always present, even in grave cardiac
disease. A feeling of discomfort or constriction, or a sense of suffocation,
is a symptom frequently present when the action of the heart is deranged
by functional or structural diseases — oftener perhaps by functional. The
importance of pain as a symptom of heart disease lies in the fact that the
onset of discomfort or pain, together with breathlessness, after slight
exertion, suggests the presence of cardiac trouble even when physical
examination reveals little or nothing.

To avoid certain yofiocie^, ascertain if there be tenderness on pressure.
If so, the lesion is probably a neuralgia of the intercostal nerves, or the
inframammary fain so common in hysteria. The latter may sometimes
be distinguished in this way from pain of cardiac origin, but occasionally
can only be recognised by the presence of other hysterical stigmata. Pain
in the prsecordial region is not infrequently associated with lithsBmia, and
may be attended by tender spots over the ribs at the apex. Empyema or
other abscess in the chest when approaching the chest wall may cause pain
and tenderness on pressure.

There are Four Groups op Causes which may lead to preecordial pain :

(a) When praecordial pain occurs as the result of Stnietiiral Disease of
the Heart, it usually consists of a diffuse dull aching, most severe at the
apex. As in other organs having a serous covering, pain is more often
present when that covering is inflamed (pericarditis) than when the sub-
stance of the organ is affected. But pain may be altogether absent ; and
it is surprising what serious valvular derangement of the heart may exist
without the occurrence of pain.

$84] PAIN IN THE CHEST— SYNCOPE 35

(6) Caidiac Pain of Fnnctioiial Qri^in may be due to (i.) pressure upon
the heart by a distended stomach or abdomen ; the differential features
of this pain are — it is greatest at the base of the heart, aggravated by the
recumbent posture, and associated with dyspnoea, (ii.) Reflex Pain may
be referred from stomach (chiefly) or uterine disorders (occasionally),
(iii.) Nervous Pain due to profound grief, sudden fright, or other violent
emotion, is of a sharp character, referred to the praecordium. It is frequent
in the debilitated, especially after prolonged nerve strain.

(c) Various Organic Affections outside the Heart and Pencardinm
may give rise to praecordial pain ; thus we may have intercostal neuralgia,
especially the neuralgia which precedes and follows herpes zoster ; pleuro-
dynia^ and many pleuritic affections. Pain in the chest is also present in
spinal caries and carcinoma of the vertebrce, and when tumours erode the
bones. The crises of locomotor ataxy may cause pain in the chest.

(d) Afigiiift Pectoris is a condition manifested by paroxysmal attacks

of extremely severe constricting pain in the chest, with a sense of suffocation

and other symptoms (see § 41).

But in cases of nnezplained pain in the chest, and in the absence of cardiac signs,
mediastinal tumour or aneurysm of the aorta, either of the arch or of the descending
aorta, ^ should always be suspected.

In the treatment of prsBCordial pain an endeavour should be made to
ascertain and relieve the cause, but much relief may be obtained tempo-
rarily by the application of an opium or belladonna plaster, belladonna
liniment, or glycerine of belladonna.

§ 24« Syncope is suspended animation due to anaemia of the brain. It
is often preceded by giddiness, nausea, and a feeling of faintness. The
face is ashy pale and the pulse and respiration feeble. Its advent is usually
sudden, but recovery, after the attack has lasted some minutes, is gradual.

Diagnosis, — Syncope has to be distinguished from epilepsy minor, which
it resembles in many respects. First, epilepsy minor (petit mat) is usually
preceded by an aura, though this is evident to the patient only. Secondly,
its advent is more sudden than S3aicope, and the return to consciousness
equally sudden and complete, for the patient in petit mal can go on with
his usual avocations immediately afterwards. Thirdly, syncope rarely
occurs without some definite determining cause, although it may be of a
trivial nature — such, for example, as a heated room, or the sight of blood.
Finally, in epilepsy minor there is generally a history of major attacks at
some time.

Causes, — Syncope nearly always arises from either structural or func-
tional derangement of the heart — more frequently the latter. A careful
examination of the heart should always be made, because, as an indication
of Structural Disease, syncope is a symptom of considerable gravity ;

^ In a case of aneurysm of the descending thoracic aorta which I have recently seen,
abnost the only symptom or sign, besides breathlessness, during eighteen months — ^up
to the time of sudden death from rupture of the aneurysm into a bronchus — was
continuous pain in the praecordial region. It extended round from the back on the
left side, and was thought to be intercostal neuralgia.

30 DISEASES OF THE HEART AND PERICARDIUM [ § 24

whereas the nervous faints of Functional Derangement are of com-
paratively little moment.

(a) The Nervous Faints due to functional derangement of the heart
are happily the more frequent. They occur chiefly in young, anamic,
and nervous females ; who, when exposed to grief, bereavement, or any
sudden emotion, or too hot rooms full of vitiated air, develop the familiar
" fainting attack." Slight transient syncopal attacks are, indeed, one of
the " stigmata " of the hysterical diathesis (§ 524).

(b) As a symptom of Stractural Heart Disease, syncope is a much
more serious matter. It is a not infrequent symptom in any form of
cardiac disease attended by enfeeblement of the heart's action, and is
serious as indicating weakness of the cardiac wall. It is more often met
with in aortic than in mitral valve disease. It may be the first and only
symptom of fatty, fibroid, or other degeneration of the heart (§ 52).
Syncopal attacks, preceded by giddiness, may arise in old people who are
the subjects of arterial thickening and degeneration, this being the cause
of what is known as " senile syncope." So important is it to distinguish
between the two kinds of fainting attacks that their differential features
are given in a table. In both there is a pallor of the surface, and there may
be feeble pidse, though the pulse in nervous faints is sometimes unaltered.
Both recover best in the recumbent position.

Other less common or obvious causes of syncope :

(a) Acting directly through the Heart. — (L) Latent organic disease of the heart, such
as fatty degeneration, which should always be suspected in obscure cases, or Stokes-
Adams disease (§ 58) ; (ii.) compression of the heart, as by corsets or by mediastinal
tumour ; (iii.) profuse internal hsBmorrhage ; (iv.) drugs and asthenic poisons acting
on the heart.

(6) Acting through the Nervous System. — (i.) Emotions and fatigue ; (ii.) violent
injury or operation ; (iii.) irritant poisons, or injury to the intestines.

(c) Acting through the Blood and Bloodvessds. — (i.) Annmia, debility, hunger, or
starvation ; (ii.) increased peripheral resistance in the arteries, with insufficient cardiac
hypertrophy ; (iii.) diminished resistance in the peripheral and splanchnic arteries,
such as occurs with excessive heat, as in hot rooms or Turkish baths ; (iv.) suddenly
assuming the erect posture, as in jumping from bed, may produce syncope in the aged ;
(v.) sometimes, in addition to the preceding, the splanchnic veins aro suddenly dilated
by emptying the bladder, and this leads to ansemia of the brain and syncope.

Prognosis. — Syncope in the young is, as we have seen, usually a neurosis,
whereas in the aged it generally means cardio- vascular degeneration. In
the former, therefore, it is usually as trivial as in the latter it is serious —
the gravity depending upon the nature of the lesion.

Treatment (see Causes above). — Place the patient immediately in a hori-
zontal position, with the head low. This may be most readily done on
the floor, but if there is little space, instruct the patient to bend forward
and lower the head between the knees. Apply ammonia to the nostrils,
throw cold water on the face, and, in severe cases, apply a mustard-plaster
over the heart. If recovery does not promptly take place, and the pulse
be very feeble, a hypodermic injection of 15 or 20 !\ of ether or brandy, or
3 or 4 IH^ of liq. strychninflB, may be resorted to. For further treatment,
see Collapse.

H25,26J

COUOH— CYANOSIS

Table I.

Gardl&C Syncope, atwodated with structural
Deningemeut of the Heart.

Usually adults ; both sexes equally
affected.

Biay come on without any apparent
determining cause, or after excessive
exertion.

Not accompanied by emotional mani-
festations.

May be f ataL

Evidences of caidio-vascular degenera-
tion and its causes.
If no signs, suspect fatty heart.

KeZTOUB Faints, iu which only the Nervous
Apparatus of the Gardlo- Vascular System
is deranged.

Females, young or at menopause.

Some determining cause always present
(e.gr., emotion), acting on the nervous
system.

Often preceded or followed by crying
or laughter, and other emotional
symptoms.

Never fatal.

Sometimes other evidences of the hys-
terical diathesis — e.g., hemiansesthesia,
ovarian tenderness, globus.

§ 25. Cough is a symptom which belongs more especially to diseases of
the lungs (§ 70), but it is met with in diseases of the cardio-vascular system
under two circumstances. Firstly, the lungs are very often involved
secondarily to the heart, especially when the right side is diseased, and
then the patient has the cough usual to pulmonary disorders. Secondly,
when the aorta, by its enlargement, presses on the trachea, or on the
recurrent laryngeal nerve, a peculiar dry, brassy, or, as it is aptly called,
" gander " cough is present, which is so characteristic as to be in itself a
diagnostic feature of aneurysm of considerable value. In pericarditis
cough may be troublesome.

§ 26. Cyanosis (Kudveo^y blue) is lividity of the surface of the body.
It is not one of the most common symptoms in heart disease, but it is one
of the most serious and unmistakable evidences of enfeebled or retarded
circulation. It is generally most pronounced on the lips, fingers, nose,
ears, and toes, and the skin may vary in colour from faint purple to almost
black. When only a slight degree of cyanosis is present; it may be
detected by closely examining the roots of the nails. Cyanosis is an
indication of deficient aeration of the blood, which may be due to (1) stag-
nation of the blood in the capillaries ; (2) defective oxygenation of the
blood ; (3) abnormal compounds of the haemoglobin.

Generally speaking, the first is the most common cause in cases where
the heart is at fault ; the second where the lungs are defective ; and the
third where there is disorder of the digestive tract. It should be remem-
bered, however, that when the heart is involved the lungs become affected
later, and that the first and second causes are to be foimd in association
in many cyanotic conditions.

38 DISEASES OF THE HEART AND PERICARDIUM [ SS «7, M

In the first class the causes to be looked for are :

1. Deficient via a tergo, as in failing compensation towards the termination of many
cases of heart disease, or of diseases in which the heart is secondarily afiected —
e,g., cirrhosis of the liver, profound tozsemia.

2. Constriction of arterioles, as in angio-neurotic cyanosis, exposure to cold and
a few other conditions.

3. Obstruction to the flow of blood through a part, as in thrombosis, when the
cyanosis is usually localised.

4. Increased concentration of the blood, as after comparative dehydration from
profuse diarrhoea or sweating, and in conditions in which the polycythemia depends
on some defect in the circulatory system necessitating an increased number of cor-
puscles to provide a sufiicient supply of oxygen to the tissues — e.g., congenital heart
disease. It is also seen in erythremia (see below).

In the second class there are four subdivisions :

1. Failure of venous blood to reach the lungs, as in some cases of congenital heart
disease where the blood is in part " short-circuited " through a patent foramen ovale.
Unless a considerable amount of blood is so short-circuited no cyanosis may be
apparent, or perhaps only the roots of the nails will show the characteristic bluish
tinge.

2. Obstructed flow in the pulmonary cireulation. This is rare but may occur in
congenital pulmonary stenosis, and when a mediastinal tumour is pressing on any of
the pulmonary vessels.

3. Deficiency of lung surface available. This is met with in emphysema and in a
variety of other conditions of lung disease and of pressure on the lung with collapse
of the lung. Pneumonia, phthisis, tumour, and sudden or chronic pleural efiFusions
are examples of this class.

4. Deficient entry of oxygen. Under this heading come cases of stenosis and
obstruction of the bronchi or trachea, as in syphilis, spasm, impaction of foreign
bodies, and pressure of tumours, such as aneurysm and goitre. Here also come cases
of cyanosis due to absence of the proper proportion of oxygen in the atmosphere, as
on the tops of mountains or in very ill- ventilated rooms.

§ 27. Eryihrnmia (Synonyms : Vaquez' disease, polycythemia vera, splenomegalic
polycythemia). — ^This is a disease in which there is an overgrowth of that part of
the marrow in which the red celb are formed. There is (i.) increase in the number of
the red cells, which may be as many as 13,000,000 per c.mm. There is an increased
viscosity of the blood, and later an increase in its volume, (ii.) The patients are easily
recognised by the redness of their complexions, which often deepens to cyanosis,
especially in cold weather. All the superficial vessels are dilated, (iii.) The spleen
is very laige, frequently reaching to the pubis, (iv.) Subjective symptoms are head-
ache, vertigo, pains in the limbs, and dyspnoea. A variety is described without
enlarged spleen, but with high blood-pressure and arterio-sclerosis. The patients
usually die in six to eight years from syncope or cerebral hemorrhage ; many of them
in [asylums.

The Treatmenl must have reference to the cause ; but in several cardiac
conditions cyanosis, if unaccompanied by dropsy, is a distinct indication
for venesection. But when marked anasarca is present, it indicates
generally that the venous stasis is too great to admit of relief by this
measure. In erythraemia bleeding gives temporary relief when the blood-
pressure is high ; when the blood-pressure is low its action is not so
certain. Inunction of mercury over the spleen is useful, and the iodides,
nitrites, and other drugs have their advocates. Arsenic is contra-indicated.

§ 28. In the third class come two rare diseases : sulph - hemoglobinemia and
methemoglobinemia.

Snlph - hnmoglobinsBmia (Synonym: Enterogenous cyanosis). ^ — This disease has
hitherto been named according to each observer's idea of ito etiology, without

1 Wcit and Clarke, the Lancd, Feb. 2, 19 J7.

{ 89 ] 8UDDBN DBA TH 39

dJBoriminating it horn the not dissimilar condition, methemoglobinemia. The most
prominent symptom is (i.) cyanosis of a greyish hue, combined with pallor ; (ii.) some
form of intestinal disorder, usually constipation, occasionally alternating with
offensive diarrhoea ; (iii) extreme weakness ; the patient may appear to be on the
point of deaUi for long periods of time. The etiology is uncertain but the disease
seems to be associated either with the presence of conditions (possibly bacterial)
which allow of the formation of some easily assimilable compound of sulphur which
is not normally present, or else with lesions of the mucosa of such a nature that the
normal sulphuretted hydrogen of the intestine is given a chance of combining with
the blood. The prognosis is good if the morbid intestinal condition reacts satisfac-
torily to treatment. Intestinal antiseptics must first be tried, and if these fail operative
measures may be adopted.

Mettusmoi^Mnnmia is a condition in which methemoglobin is found in the blood.
The most prominent symptom is (i.) cyanosis ; the tint is a bright blue and there
coexists marked pallor, (it) Offensive diarrhoea, (iii.) Weakness, dimness of vision,
vague pains, and a feeling oif collapse. There are from time to time exacerbations of
all symptoms with extreme dyspnoea, and at such times the patient seems to be at
the point of death. There may also be periods, varying from a few minutes to hours,
during which the cyanosis entirely disappears, (iv.) There is usually an ante-
cedent history of drug-taking, or of working in mines, or in the manufacture of
explosives. The drugs or fumes which give rise to this type of cyanosis are aniline
derivatives ('* antikanmia " and ** daisy " headache powders, antipyrin, veronal,
sulphonal) and benzene compounds. Pot. chlorate and some other drugs have
a similar effect, but are less often found to be in operation. In another class of case
there is no drug history, and bacteria have been isolated. In two recorded cases the
organism was of the ooli group ; in one it was isolated from the blood, and in the
ot^r from a pelvic abscess. In some cases of poisoning when a large dose has been
taken, as with suicidal intent, Uie onset of the illness is very acute.

The diagnoaia must be based on the history and the peculiar cyanosis, but can only
be verified by spectroscopic examination of the blood (Fig. 118). The prognosis is bad in
acute cases ; in others it depends on the ease with which the intestinal disorder can be
treated, and on the discovery and cessation of any causative drug. As regards ireo^
merU, the cause must be removed. Quebrachu, a drug which is credited wiUi
increasing the oxygen capacity of the blood, appeared to have immediate good effects
in one case.^ ^e usual measures for intestinal antisepsis should be tried, and
operative procedures may be required.

A Sallow Hue of the skin is characteristic of aortic valvular disease,
which in this respect presents a marked contrast to the plethoric florid
appearance of patients with mitral valvular disease. This sallowness is
distinguished from jaundice by the absence of the yellow colour from the
eyeballs and the absence of bile in the urine. True jaundice, however,
does arise in cardiac disease as a symptom of the hepatic congestion, which
is met with more often in mitral than in aortic disease.

Pyrexia and its concomitant symptoms (see Chapter XV.) are present
in most of the acuU disorders of heart and pericardiima. The temperature
in malignant endocarditis is of an intermittent or remittent type, with an
irregular range, such as that met with in other forms of septicsemia.

§ 29. Sudden Deaib, or death, say, within a few hours of the apparent
commencement of the illness, is a frequent mode of termination of
disease of the heart, and it may be the first symptom of disease of this
organ. The chief conditions under which sudden death occurs are as
follows. The first six of these have reference to the cardio- vascular system.

* Matthews, the Practitioner^ 1911.

40 DISEASES OF THE HEART AND PERICARDIUM [ {{ 80. SI

1. Among the various fonns of cardiac valvular disease, sudden death
is more frequent in aortic than in mitral disease. But sudden death,
and, in general terms, the prognosis, depend more upon the condition
of the wall than of the valves.

2. It is liable to occur in all forms of primary disease of the cardi^ic
waU — 6.^., fatty and fibroid heart (§ 52).

3. It is a very common termination to aortic aneurysm (§ 53).

4. A patient may die with the first attack of Angina Pectoris (§ 41).

5. Sudden profuse hcemorrhage, internal or external.

6. Pulmonary efnholism — e.g., from air in the veins (as in the per-
formance of transfusion), or clots passing through the heart.

7. The conditions which cause Coma may also result in death, which
is relatively sudden (§ 530).

8. Nerve diseases which in their progress involve the medulla ter-
minate suddenly ; and thus, among the rarer causes, atlanto-axoid disease
and syringomyelia may be mentioned.

9. Sudden emotion, injuries to the head, and other conditions acting
on the nervous system by shock (§ 528).

10. Suddenly-acting poisons, such as prussic acid, a large dose of
morphia or carbolic acid, aconite, veratria, etc.

11. Sudden rupture of a large cyst, an internal organ, acute disease of
the suprarenals, or other cause of Collapse (§ 168).

12. Foreign bodies in the trachea, or other causes suddenly stopping
the respiration (cuphyoDia).

13. Acute pulmonary oedema (§ 84).

14. Lymphatism.

f 80. Lymphatiim {SkUiM LymphaUcua) is a rare condition frequently unrecognised
during life, but it is important as being a cause of sudden death. There is overgrowth
of the thymus gland and of the lymphatic tissues throughout the body. There may
be no symptoms, the first evidence of the existence of the condition being death after
a trivial shock, such as a plunge into a cold bath, a hypodermic injection, or the first
touch of the knife in a minor surgical operation. Occasionally death is pieceded for
months by attacks of dyspnoea, cyanosis, syncope, and convulsive seizures. The
physical signs are often indefinite, consisting only of hypertrophied tonsils and
adenoids, and the patient is flabby and pale. In other oases the enlarged thymus
causes dulness over the upper part of tiie sternum, the spleen is palpable, and there
may be overgrowth of adenoid tissue at the base of the tongue. Subjects of this
diathesis must be guarded against any sudden shocks, or exertion, and must be warned
against rapid movements of the head and swallowing large imchewed morsels of food.
Operative measures which aim at drawing up the thymus from the thoracic inlet have
been successfully performed in Germany in a few oases, but the danger of death under
operation has made surgeons reluctant to touch these subjects. X-ray applications
have been reported as successful in some oases.

PART B. PHYSICAL EXAMINATION,

§ SI. Landmarks of the Ghest. — ^There is a ridge on the sternum formed
between the manubrium and the gladiolus which can always be felt,
opposite the second costal cartilage (c. c.) ; and the other ribs can be
counted from the second one. The nipple is usually situated just external

§82] PALPATION AND THE LOCALISATION OF THE APEX 41

to the fourth costal cartilage, near its junction with the rib ; it should
correspond to a vertical line dropped from the middle of the clavicle.
At the back, the lotoer angle of the scapula is near the seventh rib ; and
the scapular line is a vertical line drawn through the inferior angle of the
scapula. The position and relations of the heart can be studied in Fig. 11,
which is a sketch taken from the cadaver. The various regions of the
thorax named for convenience of reference are given in Fig. 33 in the
chapter on Pulmonary Diseases. The ordinary methods employed for
the physical examination of the heart, and the pericardial sac within
which it is suspended, are Inspection, Palpation, Percussion, and
Auscultation. Modern surgical methods enable us occasionally to employ
the method of Aspiration under due precautions, and Radiography is
of assistance in certain cases. Becent methods of investigating the con-
dition of the right auricle are referred to in § 35.

Inspeetion* — Note, first, the attitude of the patient, and the amount of
dyspncea present. Note also if there be any visible pulsation of the
arteries and veins at the root of his neck. In some cases it is desirable to
take a side view, and slight deviation from the normal can often be better
observed by looking over the patient's shoulder.

Secondly y most useful information may be obtained by simply observing
the aspect and appearance of the patient, for the pallor or sallowness of the
skin in cases of aortic valvular disease presents so marked a contrast to
the florid cheeks of mitral disease as to form a most valuable aid to diagnosis.
Notice also, if the dropsy of the ankles or back, which sooner or later
attends mitral disease, is present.

Thirdly, carefully observe that part of the chest wall which lies in
front of the heart. It is important to notice if there be any undue
pulsation or bulging in any part of the chest. The forcible displaced
apex-beat of cardiac hypertrophy ; the wavy, difiuse pulsation of cardiac
dilatation and pericardial effusion ; the epigastric pulsation and throbbing
jugular veins in cases of dilated right ventricle ; and the heaving carotid
arteries in cases of aortic regurgitation, may each afiord us valuable hints
as to the direction of our further inquiries.

§ 82. Palpation and the Localisation of the Apex (see Figs. 9 and 12).—
The apex-beat is the farthest point to the left at which the cardiac impulse
is distinctly felt, and after inspection, by which it can frequently be seen,
should be first palpated by the flat of the hand, and then localised with the
finger tips. In an adult male it is normally situated in the fifth interspace
about 1} inches below and i inch to the inner side of the nipple line,
at a distance of about 3 inches from the mid-sternal line. These and other
cardiac measurements vary with the age^ and proportions of the patient —

^ The position of the heart is considerably modified in childhood. The left border
comes oat to the nipple line, and the ri^ht border extends to the riffht edge of the
Btemom ; the apex beats almost directly below the nipple, behind the mth rib, or may
be in the fourth interspace.

42 DISEASES OF THE HEART AND PERICARDIUM [ § SS

facts which are apt to be forgotten. The most external portion of the
apex-beat should be marked by a dot with an aniline pencil. The
localisation of the apex is a most important matter, and there are three
principal features to observe about it — its POsmoN, its fokoe, and its
EXTENT. You may also note in passing whether a thrill can be felt with
the flat of the hand. It is important to bear in mind that the apex-beat
is considerably modified if the apex happen, as it not infrequently does,
to pulsate ^precisely behind a rib. It is only when the apex beats in an
intercostal space that these three features can be satisfactorily made out,
and this sort of fallacy should be remembered and allowed for. It can
sometimes be felt more distinctly when the patient is asked to lean forward.
In dextro-cardia the apex is on the right side.

In HYPERTROPHY of the left ventricle the apex-beat is displaced down-
wards and outwards, and the cardiac impulse is forcible and heaving.
In hypertrophy of the right ventricle there is pulsation in the epigastrium
and in the lower interspaces, but the apex is in its normal site. With
DILATATION the impulse is diffuse and wavy.

The apex is displaced downwards in cases of emphysema or pleurisy
with effusion ; if the latter be on the left side, the apex may even be
displaced beyond the right border of the sternum (see Fig. 42). The
apex is displaced ujnoards in pericardial effusion, retracted lung, abdo-
minal tympanites, or with any abdominal tumour pushing up the
diaphragm. The apex-beat is obscured by very muscular or adipose
chest walls, or emphysema. It is feeble with fatty heart ; wavy in
pericardial effusion. With pericardial adhesions there is a systolic
retraction of one or more interspaces.

Thrills. — Of endocardial thrills the presystolic thrill fdt at the a'pex,
due to mitral stenosis, is the most common. More rarely there is also a
thrill in the pulmonary area (Fig. 12), due to mitral stenosis. The systolic
thrill at the aortic area due to aortic stenosis, when present, is very marked.
A diastolic thrill can be felt over the manubrium in advanced cases of
aneurysm or aortic regurgitation. Mitral regurgitation is occasionally
accompanied by a systolic thrill at the apexy which is the commonest thrill
felt in children. A widespread thrill may be present with pericarditis.

A presystolic thrill at the fifth costo-chondral junction is very rare, and indicates
tricuspid stenosis. Aortic regurgitation is occasionally accompanied by a pre83rBtolio
thrill at the apex.

§ 88. Percussion of the superficial area of the prsecordial dulness —
i e., area not covered by lung. In mapping out this area, the percussion
stroke should be very much lighter and more superficial than that applied
when examining the lungs, or the liver, or the spleen, and other deep-
seated solid organs (see Fig. 9). The superficial area which is here referred
to is a triangular one, with the apex upwards. The measurements of the
dull area in a person of average size are 3J inches transversely, from the
mid-sternal line ; and 2J to 3 inches vertically along the left border of

I U 1 PERCVSBIOH 4$

the sternmu. Its boundaries are given in Fig. 9. The percussion note
over the sternum is very different to that elicited over the chest i>eside it —
it is of a much higher pitch — consequently, we cannot compare the per-
cussion note in these two situations. We ought, tJierefore, to percuss
upwards and downwards in a vertical line along the sternum to ascertain
if any part of it is duller than normal.

The »,m& ol deep-staled canliac dulnew U } inch la^er on enoh side, and 1 inch
htilgei upwards, than the aaperfioial ana. Its limilB are considered by most physicians
to be less oortain, and therafore less useful for di^nosis, than the superficial area.
In some schools, however, it has nupeiseded the superficial canliao dulness, and is held
to denote more accurately the variations in size of the heart.

Method. — The student should lose no opportunity of fshcobsino the HoauAL
heart and of attending to the following poinU : (i) Having frH localUtd (Ac apex-

Fig, fl.— 8upertl(ilsJanilDBepDnln«M0fH«artwidUTer.— The guperflclal area of laidlm
dnlaeu i> a triangular one, witli tbe ap«x upwards. The meaiuiements ol Chli area in a
penon □( averaca tlie are 3| inche« traniveiaeLy. uid 2) to 3 iuirheg vertically along the left
border otthe sttmnm. The right bordfiT beglni at the level ol the Joartli eoilai cartOati, and
eomapondi to a vertical line drawn slightly to the left of the middle line ol the iteranm.
lilt left limit ttirta from the oame point, and runs ontwarda along the lover border u[ tile
fourth costal <:artllage to nearlj' Ita JnncClon with the rib, then bending downwards to apex-
beat. The lower limit l> contlnnoua with the liver dulnew.

beai, begin outside the cardiac area in a. perfectly resonant area. Tlie middle fingef
of the left hand should be placed flat and ^Tndy upon the chest wall parallel to the
margin of duhiess to be made out, and movod \ inch at a time, always paraUd to that
Tnargin. towards the centre of the heart, (ii.) Use only one finger — the second of the
tight hand — as a hammer, making a short sharp tap with the finger lip. The per-
cQsging finger should rebound immediately — " staccato." as pianists say. The
movement should be made from the wrist, or from the knuckle (metacarpo 'phalangeal
joint), as in playing the piano, and the tap should be a light one. (iii.) By listening
attentively to Urn sound elicited, it will be notictrfl that it is dull and fiat over the
heart, like that produced by striking any solid object ; but louder and more resonant
outside the area, like the sound produced by striking an empty barrel. It is only
possible to define in this way the right, tho api>cr, and tho loft limits of the dull area,
bocause at tho lower limit the cai'diac duliiess ia continuous with that uf the liver.

4t DISEASES OF THE HEART AND PERICARDIUM [ § 84

Mark with a blue aniline pencil the right or sternal border in two places. The curved
upper and left border of the dulness should also be marked by a pencil in two positions
— viz., close to the left side of the sternum, and in another place near the nipple ;
these can then be joined and continued to the apex- beat.

Fallacies. — It should be remembered that cardiac enlargement may
be obscured by the hyper-resonance of emphysematous lungs, and under
these circumstances enlargement of the heart or pericardium is very
difficult to make out. We have then to rely upon other means than
percussion. On the other hand, cardiac enlargement may be simulated
by a fibrous retraction of the left lung, the heart, nevertheless, remain' ng
of normal size ; or, thirdly, the heart may be displaced by an aneurysm or
other mediastinal tumour pushing forward, and making the prwcordial
area appear larger. One or other border of the area of dulness may be
obscured by pleuritic effusion. Ascites, pleural effusion, or abdominal
distension may actually displace the heart (see case in Fig. 42, § 84).

The boundaries of the praecordial dulness are of great importance — so
much so that we are enabled, as we shall see, to classify both acute and
chronic diseases of the heart by the presence or absence of enlargement.

The CHIEF CAUSES OP ENLARGEMENT of the prsBcordial area of dulness
are two in number — effusion into the pericardium, and enlargement
of the heart. The latter may be due to hypertrophy or to dikUationy or,
more commonly, to a combination of the two. This enlargement may
involve any one, or more than one, of the cavities of the heart.

§ 34. For Auscultation much practice is required, and once more I
must warn the student never to miss an opportunity of listening to the
sounds of the heart, particularly the normal sounds. The whole cardiac
cycle — i.e.y contraction (systole) and dilatation (diastole) — occupies about
one second (Fig. 10). The first sound is due to the contraction of the
ventricular muscle or to the closure of the mitral and tricuspid valves
(or to both), and occupies about ^*^ second ; then comes a very brief
interval, say ^',y second ; followed by the second sound (jjf second), which
is due to the closure of the aortic and pulmonary valves ; and, finally,
the diastolic interval {{'q second). (Fig. 10 should be studied carefully
by the student.)

Methods. — If no stethoscope is handy, cover the patient's skin with a soft hand-
kerchief, preferably silk, and apply the ear ; but a stethoscope localises the sounds
better. Personally, I prefer the old-fashioned wooden stethoscope, if the earpiece
fits my ear well. But the binaural stethoscope is very useful for examining infant-s,
or whenever there is any noise in the room or in the street, though it always has the
disadvantage of giving more resonance tones (echoes arising in the cup and tubes).
Place the small end of the stethoscope on the chest over the apex-beat, so that the rim
touches all round, and then adjust your ear to the stethoscope, not the stethoscope to your
ear. The common fault is to allow one side of the chest end to be raised off the chest
in the process of adjusting the stethoscope to the ear. Do not allow the weight of
your head to rest on the stethoscope ; it pains the patient, and you do not hear as well.
It is a good plan to keep your fingers on the pulse (wrist or carotid) whilst auscultating.

Listen, first, to the sounds at the apex and all round its neighbour-
hood. Notice that the first sound is normally longer and duller than the

§»4]

AUSCULTATION

second,! and that the two sounds somewhat resemble lubb (yV second),
<i^P (A second). Then, secondly, listen at the base ; place the instrument
over the second right intercostal space, close to the sternum, over the

NORMALI ^yg^
SOUNOSj \ J /

VENTRICULAR

_i-

SYSTOLE.

DIASTOLE.

of cardiac cycle

closure of

mitral &

tricuspid

valves

of cardiac cycle.

closure
aortic h
pulmonary
valves

OTHER
tVENTS

)

MURMURS.

THEIR 1
SIGNIFICANCE/

expansion
of aorCa.

Illllinniiih

SYSTOLIC
MURMUR

^^ •

nr^itral

Iregur^iCaCion
or
dorDic
sDenosis.

aortic
recoil.

ricH
ar

lau
;uL.

isystole

llliuaj.

DIA5T0UC
MURMUR

9^ m

MBS •

aortic
regurg^.

PWSrSTOLIC
MURMUR

o'
CO-

mitral
stenosis.

:j)jf.

Fig. 10. — Diagram of a Cirdiac Cycle, showing various events and ttieir duration, how the
different mnrmuis are produced, and their clinical significance. The student should study
this and Fig. 12 very closely.

aorta. Thirdly, listen over the pulmonary area, between the second and
third left spaces ; and, fourthly, listen over the tricuspid area, at the left
side of the fifth costo-chondral junction. The student will notice that

^ The first and second sounds correspond to G and B-flat respectively, below |the
middle octave.

le bod; o[ ths 4th Don. Vert.

Root of R. lung.

11. — The BMrt Uld QreKt Veuela in Bltn, via\ )uiig8 turned l»el[, skctrJied from tiit
pBdkver Bifht ventricle forniB neater part of the interior lorface of the heart. Above
and to right ol thla la the right auricle, into vhlch the luperlor vena cava openi, which collects
the blood from the two Innominate veloi. PaHlng out from and above the right ventricle
Is the pulmonarr artery, above which again it the remslnt of the ductna arterloaiu, connecting
" — '"■ "■« arch oJ the aorta. Jmtto the left ol the pulmonary artery the left aurlcnlar

appendix peepa round the comer. The arch
left ventricle (which 1> at back, and therefore only
upper convexity arlae

.In Older the in
trachea la aeen behind the veaaela, and
Ft paaalng down Id front ol th

margin of heart), and froi
-tery, left carotid, and Intt anbclavlan.
phrenic and vsel nervet are leen at the tidei, thme

5H]

AUSCULTATION

the actual position of a valve (Fig. 11) does not correspond precisely with
the portion of the m&ximum intensity of the sounds produced at that
orifice (Fig. 12). This should always be the order of investigation, and
by listening in this manner, we are enabled to make two important observa-

Flg. 12. — DiAO&Aa aHowmo t

\ Bitnatioii o

B OudUc T&lVM A

) THK pOlltlOIL i:

p - Pnlmooaiy oriflca, at level at upper border ol third ]«ft coatal wrtllage.

s = Aortic orlDce at level of lower border of third leftRoaUl cuilbiee.

n - Kltr«l orifice »t level of lowat border of lomth left cottsl cartUige.

I ^ Triciuirid orl£c« at level ot [onrth Intacepace, lying obllqnely behiad the etemum.

The potltloni where the eoiuidt prodnced at the varloiu orlBcee are beit heard are Indicated
by the lett«ii encloied In cltclei. The arrows mark the direction In whicb mocmun produced at
Um oaiMpondlDS orlfieM are conducted.

H. Ultra! mnrmnn ara b«(t heard at Vtit mitral arsa — i,t., the apex.

A. Aortic mannim are best heard at the aorUc area— <.<-, aecoad right eo«eal oarUlage.

p, Palmonary mncmDra are beat heard at the pulmonary area — i.e., lecond left intercostal spare.

T, Tricutpid manuDn are best heard at the trlcnipld area — 1.(.. atlovprend ot fltcrnuin.

tiona : (i.) The presence or absence of a mukmur (peri- or endo-cardial) ;
(ii.) whether either sound is unduly shortened, prolonged, accentuated, or
duplicated.

If a murmur or bntU be discovered, there are four qualities to be observed
concerning it : (i.) Its time (i.e., whether it replaces the first or second

48 DISEASES OF THE HEART AND PERICARDIUM [§85

sound) ; (ii.) its position of maximum intensity ; (iii.) the direction in which
it seems to be conducted (i,e., continues to be audible) ; and (iv.) its quality
as regards roughness. These may be briefly summarised as Rhythm,
Position, Conduction, and Character. A systematic method of this kind
is easily acquired, and the habit will afterwards be of the greatest use.
It is by the cultivation of such habits that the good clinical observer is
made.

Alterations of the Heart Sounds and their Significance.

1. Murmurs heard with the first sound are systolic in rhythm ; murmurs
with the second sound are diastolic (see Fig. 10). There are four funda-
mental facts which the student must never forget, viz. :

Systolic m. at apex continued into axilla —mitral regurgitation ;

Presystolic m. limited to apex = mitral stenosis ;

Systolic m. in aortic area, conducted along carotids = aortic stenosis ;

Diastolic m. at aortic area, conducted down sternum = aortic regurgitation.

Stenosis {oTevoot, to contract) indicates obstruction or narrowing of
an orifice ; regurgitation indicates a backward flow from imperfect closure
of the valves.

2. Accentuated second sound in the aortic area, at the base of the heart, is met with
when the arterial tension is high (§ 61), or in aortic aneurysm. In the pulmonary
area an accentuated second is due to increased blood-pressure in the lungs, as in
mitral valve disease.

3. A reduplicated second sound at the b€ise of the heart is found when the aortio and
pulmonary valves do not close S3mohronously, as when the pressure in either the
arterial or the pulmonary system is unduly high (as in 2). When heard a little to the
right of the apex it is very characteristic of mitral stenosis. A reduplicated first at the
apex is sometimes found with high arterial tension.

4. Short, dear, sharp sounds are found with cardiac dilatation, while fedU sounds
occur with fatty or fibroid heart. Emphysema, excess of adipose tissue, and pericardial
effusion, obscure the sounds, and give the impression of feebleness.

6. A prolongation of the first or second heart sound is sometimes spoken of, but
it is difficult to know where to draw the line between a prolongation and a murmur.
A ** booming " first is found with hypertrophy.

Fallacies. — Under ordinary circumstances the respiratory do not
interfere with the cardiac sounds, but if they do, the patient should be
asked to stop breathing for a few seconds. It is often wise to do this
in any case, because sounds originating in the bronchi or pleura may be
mistaken for cardiac murmurs, but they cease when the patierU stops breathing.
On the other hand, if a murmur be very feeble and doubtful, the heart
sounds may be exaggerated by causing the patient to take some exertion,
such as running upstairs (see § 47 for variations in murmurs).

§ 85. The Pulse affords one of the best possible indications as to how
the heart is performing its work, as to what remedies are indicated, and as
to how the therapeutic measures we have already adopted are answering
their purpose. The pulse also gives an important clue as to the nature of
the cardiac lesion ; thus, in mitral regurgitation the pulse is usually rapid,
of low tension, and may be irregular, whilst in mitral stenosis it is regular, but

§36]

THE PULSE

small, thready, and incompressible ; in aortic regurgitation it presents a
collapsing (^'water-hammer") character, whilst in aortic stenosis it
presents exactly the opposite feature, being sustained. The pulse will
be dealt with fidly in a separate chapter (§ 55), but there are three important
hints which may be mentioned here — viz., (1) Do not examine the pulse
until the nervousness at first excited by your visit has passed ofiE ; (2) gener-
aUy keep your fingers on the pulse while auscultating the heart ; (3) in all
cardiac cases the rate, rhythm, force, and tension of the pulse should be
frequently noted.

Fig. 13. — SimultaneouB tradngB firom the jugular and radial poises from a patient with a normal
heart. The jogolar pnlse is of the anrioular form, and shows a large wave (a) due to the
aaride. The rhsrthm is regular. The space b represents the period of yentricular systole.
{J)f. Jamet Maekmtie.)

The pulsation of the jugular veins in the neok may give valuable assistance in
determining the condition of the auricles of the heart. The poltobaph is an
instrument by which one can obtain simultaneous parallel records of the action of the
jugular (venous) pulse and the
radial (arterial) pulse. The
venous tracing reveals the con-
dition of the right side of the
heart just] as the tracing of
the artery (or of the cardiac
apex) reveals the condition of
the left side of the heart
(Fig. 13). The interpretations
of tiie records in cardiac disease
can only be correctly judged by
the expert skilled in their em-
ployment. The venous tracing
shows in normal conditions two
waves. The first (a) is duo to
contraction of the right auricle,
and is followed by a depression
indicating the relaxation of
ihe auricle. The depression
is broken by a small rise

(e), probably communicated to the jugular vein by the carotid. The second wave
(v) represents the ventricular contraction. The interval between the first and second
waves occupies about one-fifth of a second, the time of the wave of contraction passing
from auricle to ventricle. The venous tracingshows a definite change when auricular
fibrillation (f 50) supervenes. The first auricular wave is replaced by numerous tiny
waves (fibrillation), duo to the undulatory independent twitchings of the muscular
fibres in the right auricle ; and the tracing shows only a ventricular wave (Fig. 14).

Fig. 14. — Simultaneous toaciugs of the Jugular and radial
pulses firom a patient with auricular fibrillation. The
jugular pulse is of the ventricular form, and there is an
absence of the] wave {a), due to the auricle, preceding
the carotid wave («) as in Fig. 13. The rhsrthm is
irregular. The space B represents the period of ventri-
cular systole. (Dr. James Maekemie.)

60 2)18EA8£!8 OP fHH HEARf AND PEMtCARbtUM [ JJ a6, $7

Tho ELECTBO-OABDiooBAM shows the Contractions of tho heart. The electrical
discharge which is set up by contraction of tiie cardiac chambers is conducted to a
string placed between the poles of a magnet, and the movements of the string are
projected on to and recorded on a photographic plate.

PART a DISEASES OF THE HEART AND PERICARDIUM : THEIR
DIAGNOSIS, PROGNOSIS, AND TREATMENT,

§ 86« Glassiflcatioiu — For practical purposes, diseases of the heart and
pericardium are best grouped into Acute and Chronic ; and the latter
may be subdivided into those attended by erUargement of the prcBcardial
didneas and those not necessarily so attended.

Aeute. Chronic.

AREA OF DULNESS INCREASED.

I. Cardiac hypertrophy.

I. Acute pericarditis.
II. Acute endocarditis.

III. Neuro-palpitation (paroxys

mal tachycardia).

IV. Angina pectoris.

II. Cardiac dilatation.

III. Hydropericardium.

IV. Congenital heart disease.
V. Aortic aneurysm.!

AREA OF DULNESS NOT
NECESSARILY INCREASED.

I. Chronic valvular disease.
II. Fatty heart.

§ 37. Routine Procedure. — First : What is the Patient's '' Leading
Symptom " ? It may be that the patient voluntarily complains of one
of the symptoms discussed in Section A, and in this way has directed
our attention to his heart. If not, we must ascertain, without putting
" leading questions," what is his " chief symptom." Breathlessness is
the most constant symptom in cardiac disease, and in more advanced
stages we meet with dropsy and cyanosis.

Secondly : Having obtained this clue we follow it up by asking a few
details, in chronological order, of the History of the Illness. In this
way we ascertain whether the disease he acute or chronic — a most important
matter, because for clinical purposes diseases of the heart and pericardium
may be primarily divided into acute and chronic. The Previous and
Family Histories may also be inquired into. In all cardiac cases it is
important to know whether the patient has ever had acute rheumatism,
this being the most frequent cause of cardiac valvular disease. Ascertain
also if there be any heart disease in the family.

Thirdly : The Examination of the Heart, and especially the decision
as to whether there is any enlargement or not. The routine method consists
of the following procedures : —

^ This is not a disease of the heart proper, but is included here because its existence
is often revealed by finding enlargement of the prsecordial dulness, or dulnees above,
meiging into that of the heart.

SS8] ACUTE PERICARDITIS 51

1. An examination of the apex- beat (by inspection and palpation) ;

2. The mapping out of the area of pracordial dulness (by percussion)
(see Fig. 9) ;

3. Listening to the heart sounds (auscultation) ; and

4. The examination of the pulse.

The chest should always be stripped and a thorough examination made.
An attempt to examine a female patient should never be made without
the removal of the corsets. The patient should be examined both in the
recumbent and the erect posture.

If the sjrmptoms of which the patient complains point to some Chronic
Caidia3 Disease — i.e,, they have come on gradually and are unattended by
pyrexia or other constitutional disturbance — the reader should turn to the
Chronic Diseases (§ 42).

If, on the other hand, the disease is of an Acute character — i.e., it has
come on recently or suddenly, and is perhaps attended by pyrexia and
other constitutional symptoms — it is one of four diseases : I. Acute
Pericarditis ; II. Acute Endocarditis ; III. Paroxysmal Tachy-
cardia ; or IV. Angina Pectoris.

I. The patient is in evident distress, and the prcecordial area q/* dulness is
increased, the shape of the duiness being pyramidal, toith the point upwards,
and the temperature is elevated. The disease is probably Acute Pericarditis.

§ 38. Acnte Pericarditis is an acute inflammation of the pericardial
sac. The disease has two stages : the first precedes, and the second
follows, the efEusion of fluid into the pericardial sac. It is not infrequently
met with as a primary afiection. It supervenes during the course of
many different diseases, and the symptoms of these may mask its onset.
Rheumatic fever is certainly its most common cause, and it should be
remembered that it may be the first manifestation of this affection.
We should always examine the heart daily in rheumatic fever, and in
acute renal affections, because in these acute pericarditis may come on
insidiously, without pain or tenderness, its advent being maiked perhaps
only by the occurrence of delirium, so rare otherwise in acute rheumatism.

Symptoms, — (1) The patient wears an anxious, troubled look, and the
cheeks are flushed or pallid ; there are fever and a rapid pulse ; the
breathing is rapid, and he complains of severe pain over the heart (occasion-
ally referred to the abdomen), increased by pressure, movement, or respira-
tion. (2) Physical Signs. — The prsecordial dulness is only slightly increased
at first, but a loud, harsh double friction sound, " to and fro," like a saw,
is heard on auscultation. This may be distinguished from a murmur
produced within the heart by (i.) always being double (i.e., accompanying
the movements of the heart) ; (ii.) the second part of the rub is continuous
with the first, without any diastolic pause ; (iii.) it is often loudest at the
root of the great vessels, over the third left costal cartilage ; (iv.) it varies
in its character from time to time, and is increased by gentle pressure with
the stethoscope ; (v.) pressure will also elicit another differential character

HARVARD uNivERsrrr

fCHOOLOF MEDICINE AND PUBLIC HiALHI

LIBRARY

62 DISEASES OF THE HEART AND PERICARDIUM [ § 88

— viz., that the disease is usually accompanied by tenderness, as well as pain.
The differentiation between peri- and endocardial murmurs is so important
that it is also given in a tabular form below (p. 55). To distinguish peri-
cardial from pleuritic friction is very easy, because the latter ceases if the
patient holds his breath. Note that as the efihision occurs the murmur
becomes less distinct, but it is again intensified as the effusion clears up.

(3) Second Stage, or stage of pericardial effusion. The inflammation
may subside, but more frequently, in the course of a day or two, effusion
of fluid occurs, and the pain and tenderness diminish. The rub becomes
less audible, though it can still be heard at the base of the heart. The
temperature may fall a little, but the breathlessness and other symptoms
continue. A troublesome cough is frequently added, and dysphagia and
vomiting sometimes occur. The increased area ofdul/ness, due to pericardial
effusion, may be greater than the enlargement from any other cause,
(i.) It is of triangular shape, with apex upwards, reaching to the third,
or even second, costal cartilage, (ii.) As the root of the heart is fixed to
the pericardium, when the sac fills the whole heart becomes raised, and,
therefore, the apex beats above and to the left of its normal position, (iii.) The
dulness extends to the left of the apex-beat. There is progressive weakening
of the heart sounds at this time, because they are transmitted through
fluid. It is possible by the height of the dulness along the sternum, which
should be watched each day, to determine the amount of fluid present.
Ewart describes a square patch of dulness with absence of R. M. at the
base of the left lung.

Etiology, — Pericarditis may attack any age and either sex, but is almost
always preceded and cau^d by some other disease. It is doubtful if
idiopathic pericarditis ever occurs. The causes of pericarditis may be
ranged under five heads : (1) Injury, (2) Certain acute infections : acute
rheumatism, pyaemia (staphylococcal, streptococcal, pneumococcal), scarlet
fever, variola, typhus, typhoid, and influenza (Barlow), and some consti-
tutional diseases — Bright's disease, scurvy, gout. (3) Chronic infections —
e,g,y tubercle. (4) Morbid growths — e,g., cancer. In the two last the
process tends to be subacute, and is accompanied by a large amount of
fluid. (5) Extension from adjacent organs, amongst which may be men-
tioned pleurisy or pleuro-pneumonia, especially on the left side ; intra-
thoracic aneurysm (pericarditis may be the precursor of rupture into the
pericardium) ; solid intrathoracic tumours ; perforating ulcer of the oeso-
phagus ; various diseases below the diaphragm — e,g,, abscess or hydatid
of the liver.

Course and Prognosis, — The duration of acute pericarditis with effusion
varies widely, but it averages about fifteen to twenty-five days. It may
undergo resolution with or without the formation of adhesions (Adherent
Pericardium, § 38c below) ; or result in chronic effusion (Hydropericardium,
§ 45) ; or become purulent (Pyopericardium, § 38a below). Pericarditis
with effusion is always a serious malady, but the prognosis depends much
on the disease which it complicates, the general condition of the patient, and

S»8] ACUTE PERICARDITIS B3

the evidences of cardiac embarrassment — namoly, dyspnoea and cyanosis
with feeblBseas, rapidity, and irregularity of the pulse. Pericarditis com-
plicating rhenmatism, like the olher complications of that dieease, tends
to vecovpr. but it may leave a weakened heart, and lead to cardiac
dilatatiun. In renal disease it is a (terions though often latent affection ;
and in pyemia, when it is generally purulent, it adds to the gravity of that
mHoub disorder. In infancy and in debilitated patients it is alec grave.

Diagnotii. — The diagnosis from acute endocarditis has been considered
above, and in Table II., p. 55. It is distinguished from dilatation by
the following points : the left border of the dulnesa in pericardial effusion
extends beyond the apex-beat, and the apex-beat may be displaced
upnrards ; the right border of dnlness has a convex outline and the cardio-

tlg, IB. — DiAOiuk noH A Case or Bheciiitio Pebioardttib n .

tweDt7-wven. The ditrk uea inilleBtM pnccordlaL dulcsaa. The lugei — _,^

■hwUng bIvm Uw vra over which the pericardial [rictlon could be heard (londneu ii Indicated
by the dgpUu of the shudlng). It 1> uaually tauKlit that one of the [eatnret dlKlnsuUhlnK
perl- trom endo-cardlal mnnnnn it the limitation ot the roTmei ta the precordial region .
but I have numy Umea utiafled myieif that thli li not lo. and thli case li one ot leveml
examplea I have met with TfliiOed by aulnpay. Thlicsue watanderthe careol Dr. W.H.Ord
when I wM hlB honae-phytldan.

hepatic angle at the right fifth intercostal space is dull (Rotch's sign).
X-ray examination shows obliteration of the normal space between the
diaphragm and the heart, and sometimes the heart outline can be made out
distinctly within that of the distended pericardium.

Treatment, — In the inflammatory stage the patient should be kept in
bed absolutely without movement, on light fluid diet ; and cotton-wool,
a poultice, or warm fomentation applied to the prtecordium. This usually
gives more relief than the ice-bag which is recommended by Dr. Lees,
though this undoubtedly relieves the symptoms. If the distress is great,
wonderful relief is obtained from four or live leeches over the pnecordium.
If cyanosis, orthopnoea, and irregular pulse are present, indicating con-
siderable cardiac embarrassment, bleeding (4 to G ounces) is a prompt and
efficacious measure. Opium (gr. ^ quartis horis], or morphia hypodermi-

54 DISEASES OF THE HEART AND PERICARDIUM [ §88a

cally, is of great value for the pain and distress. Small doses of chloral
may be given for the restlessness if the circulation is well maintained.
Effervescing salines should be administered. Digitalis is given in small,
frequent doses for cardiac failure, and stimulants, ether, and strychnine,
according to the state of the pulse. The effect of digitalis must be very
carefully watched, lest it increase the cardiac embarrassment. For hyper-
pyrexia and delirium some recommend the graduated bath, but the
necessary movement is a grave objection ; and we have remedies quite as
valuable in antifebrin, phenacetin, aconite, quinine, and opium.

Tf&Ument for the cause of the pericarditis should be combined with
the foregoing — e.g., sodium salicylate combined with alkalies for acute
rheumatism ; diuretics and hot-air baths for renal disease ; quinine in larger
doses for pysemia. In the stage of effusion free blistering promotes
absorption, but it must be remembered that renal disease is a contra-
indication to blistering. If the effusion becomes chronic, potassium
iodide (gr. v. t.i.d.) and diuretics may be given (P. 55). Iodine paint and
other local counter-irritants are also useful.

Pabacbntesis PsRiGARDn. — If, at any time, the effusion be considerable, and the
cardiac embarrassinent veiy great, as evidenced by severe dyspnoea, and a rapid,
irregular, low-tension pulpo ; if leeches and bleeding have failed to give relief, explora-
tion with a hypodermic syringe, under strictly antiseptic precautions, may be practised
io ascertain (he nature of the fluid. If clear fluid be found, paracentesis should be
performed, and the ope ration may be done without fear, if rigid antiseptic precautions
be employed, and the point of the trocar kept away from the viscus. Incise the integu-
ment in the fifth left interspace, close to the sixth rib, 2 to 2^ inches to the left of the
middle of the sternum (in an adult of average size). Lisert the trocar and cannula
perpendicularly to the surface ; withdraw ^e former directly it pierces the wall.
Eight or twelve, or even forty ounces (in a chronic case) may be thus gradually removed.

§ 88a. Pyoperioarditii. — Sometimes in debilitated children and in the course of
scarlatina, in phthisis and empyema, always in the pericarditis of pyaemia, and under
some other conditions, the fluid in the pericardium takes on a purulent or sero-purulent
character. This condition is sometimes revealed (as in a collection of pus in other
parte of the body) by the occurrence of (1) shivering attacks, (2) profuse perspirations,
and (3) a temperature with wide variations in the coursa of a few hours, in addition
to the clinical features of acute pericarditis above described. But it is very difficult
to diagnose, because the friction sound is usually absent. It is usually fataL

Pyopericarditis is the form which pericarditis frequently assumes in infancy, and
is then extremely difficult to diagnose. In addition to the small measurements with
which we have to deal, the left lung may become adherent to the chest wall early in
the disease, and so prevent the recognition of the enlargement of the prsBcordial dulness.
It is only by the profound disturbance of the circulation, the progressive weakness
with anaemia and leuoocytosis, that we can assume the presence of pus.

Pyopneumocardium is a rare condition in which air reaches the pericardial sac from
the lungs or stomach.

HcBmopericardium is very rare. Aneurysm of the first part of the aorta or of the
cardiac wall, rupture or wounds of the heart, scurvy and other blood diseases, may
lead to sudden death owing to the sudden influx of blood into the pericardium. A
small amount of bleeding may be seen in the pericarditis due to Bright's disease,
malignant growths, and tubercle.

Treaiment, — Quinine in large doses, phenacetin, and like remedies, may be ad-
ministered, but a large hypodermic syringe, rendered thoroughly antiseptic, should
be very carefully introduced whenever the existence of pyopericardium is suspected.
If the fluid withdrawn be of a purulent nature, paracentesis, or, better still, free
drainage, should be e£fected.

M t86, 88c 1 P Y OPE RICA RDlTlS^LA TENT PERICA RDITIS 55

§ 88&. Latent Perioarditif — i.e.* perioarditis without symptoms (though not neces-
sarily without physical signs). In most patients in whom we find a pericardial
effusion a history of acute pericarditis is obtainable ; but it is a faxit not sufficiently
recognised that pericarditis may have come on quite insidiously, without any acute
symptoms. The effusion may bo discovered when examining tiiB heart as a matter
of routine, or perhaps not until the autopsy. Moreover, I have, in the post-mortem
room, on more than one occasion foimd a totally adherent pericardium in a patient in
whom the most careful inquiry had failed to reveal any 33rmptom3 pointing to the
heart during life (§ 47). It is a latent pericarditis of this kind which ordinarily com-
plicates RxNAL DissASE. In AouTB Rheumatism also Us advent may he inikaUd
only by delirium or votniting ; and Gouty persons also may be attacked by this latent
disease after exposure to chill.

Pericarditis occasionally results in Adherent Pericardium.

{ 88e. Adherent Pericardiiim may exist in two forms : (i.) The internals in which
the visceral and parietal layers become joined, so that the heart is shut up, as it were.
in a box. and is incapable of much hypertrophy. The symptoms are those of grave
cardiac failure, which usually come on severely, and often end fatally at about puberty,
when the heart should increase proportionately with the general development.

(IL) External, in which the pericardium is adherent to the surrounding structures,
the pleura, mediastinum, and diaphragm. The symptoms are those of cardiac
embarrassment out of proportion to the signs of heart disease found. The signs are
many, but not very reliable. They are (1) a systolic tug at the apex ; (2) fixity of the
cardiac apex during respiration and with change of position ; (3) systolic recession
along the attachments of the diaphragm, either in front along the lower costal border,
or behind under the eleventh and twelfth ribs ; (4) signs of hypertrophy, greater than
can be accounted for by the severity of any valve disease which may be present ;
(5) pulsus paradoxus, or stopping of the pulse during inspiration. Cardiolysis or
removal of ribs has been succemfnlly performed for this condition.

We now pass to the other acute disorders — viz., II. Acute Endo-
carditis ; in. NEURO-PALprrATiON ; and IV. Anoina Pectoris.

II. The prcBoardial area of dolneM is not neoeisarily inereased, the
jxUient is in evident distress, his temperature is elevated, and on attsctd-
toting the chest there is a murmur added to the heart sounds — the disease is
probably Acute Endocarditis. It is not always easy to distinguish
endocardial from pericardial murmurs (see table below).

Table II. — ^Diagnosis of Endocardial from Pericardial IUurmurs.

Endocardial Murmurs. Pericardial Murmurs.

1. May accompany first or second sound
only, or both. If double, there is
always a short interval of silence

Always double, and can be heard
throughout the diastole, as well as
the systole, without any interval

between the two bruits. between the two bruits.

2. Loudest in one of the valvular ; Usually loudest over third left costal

areas. | cartilage (root of big vessels).

3. May be conducted into the axilla, i Mostly confined to the praacordium. ^

or along the aorta and carotids.

4. Usually no pain or tenderness.

Usually accompanied by pain.

* For an exception to this, see Fig. 16, p. 53.

56 DISEASES OF THE HEART AND PERICARDIUM (§89

§ 89. Acute Endocaiditii is acute inflammation of the valves of the
heart. It is usually attended by an almost imperceptible enlargement
of the precordial dulness^ because a degree of dilatation or myocarditis
is associated with it. In a very large proportion of cases it complicates
some other disease ; and, like pericarditis, it is very frequently associated
with acute rheimiatism ; it may even be the first evidence of that disease.

There are two varieties of endocarditis, commonly known as Simple
and Malignant, and there are three groups of symptoms found with each.

In Simple or Benign Endocarditis, as in the other variety, (1) the
characteristic feature is the devdopnerU of a murmur^ usually heard
loudest at the apex because the mitral valve is the one most frequently
involved in acute rheumatism ; but it may be heard in any situation,
depending on the valve affected (see p. 73), and it may be single or double
in rhythm. The murmur has to be diagnosed from that of pericarditis
(see table above), and, if possible, from that due to old valvular disease.
In the acute disease the murmur is usually softer and heard over a more
limited area ; in old valvular disease it is harsher, and is conducted in
different directions (vide Cardiac Valvular Disease, § 47). The previous
history, and the presence of cardiac dilatation, may also aid us consider-
ably. The other physical signs which are present are a weak, diffuse
impulse and weak cardiac sounds.

2. The Constitutional Symptoms may be so few and slight that at the
time they may pass almost unnoticed. But since simple endocarditis
usually complicates some other disease (e.g., acute rheumatism), the
constitutional symptoms largely depend upon the severity or mildness of
the primary disease. The onset of the endocarditis in these circumstances
may be suspected when there is a sudden increase in the rapidity of the
heart, and an additional rise of temperature without apparent cause.
Palpitation may be present, but pain and distress about the prsecordium
are generally absent — a feature worth bearing in mind. In the rare
instances in which acute endocarditis occurs primarily, the temperature
is irregularly intermittent (100*^ to 102*^ F.). The presence of such a
pyrexia, and the absence of physical signs, excepting those referable to the
heart, are the only data upon which we can rely for the diagnosis of the
disease.

3. Emboli do not usually occur, at any rate, imtil very late, in simple
endocarditis attacking a heart previously healthy. But when it attacks
a heart the seat of old valvular mischief — known sometimes as Recurrent
Endocarditis — the temperature may vary from 100° to 102*^ F. for days,
weeks, or even months, and emboli may arise in various situations from
the separation of the inflammatory material on the valves. Rigors, with
tenderness and enlargement of the spleen, may indicate embolism of that
organ ; sudden hemiplegia or other nerve troubles may point to embolism
in the brain ; sudden occurrence of bloody albuminous urine, with a rigor,
point to embolism in the kidney ; sudden blindness, to embolism of the
central artery of the retina ; sudden pain and tenderness in a leg or

§ 89 ] ACUTE ENDOCARDITIS 57

arm may indicate plugging of one of the arteries, in which case the pulsation
will be absent below the blockage ; and sudden abdominal pain with
vomiting and collapse may follow embolism of the mesentery.

Causes of Benign Endocarditis. — A history, or evidence at the time, of
the causes of endocarditis may help us in the diagnosis, (i.) Undoubtedly
the most common of these is rheumatic fever, old or recent, and it shoidd
be remembered that acute endocarditis may arise quite early in the course
of the disease, before the joint lesions are manifest. Exposure to cold is
mentioned as a cause, but the endocarditis in such cases is probably of a
rheumatic kind, (ii.) Chorea, scarlatina, typhoid, and many other bac-
terial infections, may give rise to endocarditis, (iii.) It is also an occasional
complication of syphilitic,^ cancerous, and other cachectic conditions,
chronic alcoholism, and renal disease, (iv.) Valves deformed by acute or
chronic endocarditis are predisposed to acute inflammation, and the
recurrent endocarditis above referred to thus arises, (v.) The patient is
generally yoimg, rarely older than thirty-five or forty when attacked by
endocarditis for the first time, (vi.) Heredity is an important predisposing
factor.

The Diagnosis of benign endocarditis has been referred to above (under
the constitutional symptoms), and it is not usually difficult. It is most
important, however, to distinguish the two forms of endocarditis, as they
differ so widely in their duration and fatality. Malignant or ulcerative
endocarditis differs clinically (1) in the greater severity of the constitutional
sjrmptoms, which may present all the features of septiceemia or of the
typhoid state ; (2) in the wide range of the temperature in the course of
twelve or twenty-four hours, and the occurrence of severe rigors and
sweats ; (3) in the invariable occurrence of systemic emboli, which may be
of an infective character. When, however, malignant endocarditis super-
venes on a previously damaged heart the diagnosis may become extremely
difficult.

The Prognosis, though the malady may last for many weeks, or even
months, is favourable as regards life, but the damage to the cardiac valves
is generally permanent, and then the prognosis turns on many important
considerations (§ 50).

Treatment should be directed primarily to the disease of which endo-
carditis is a complication — salicylate of soda, for instance, for rheumatic
fever, though this drug is usually thought to have no control over the
cardiac lesion. Perfect rest — hardly allowing the patient to turn in bed —
is absolutely essential. This not only favours the subsidence of the
inflammation, but prevents the violence of cardiac action, which separates

^ H. L., a lad aged fiftoen, was admitted into the Croydon Hospital in 1882 with
intense chlorosis, intermitting pyrexia, and a loud endocardial murmur. The cause
of his ilbiess was obscure during life, but he died gradually of asthenia. After death
gammata were found involvng the cranial and other bones. There were striae in
the cornea, and other evidences of syphiUs, and abundant evidence of acute recent
endocarditis, and a generalised endarteritis. This case is referred to at greater length
io the Clinical Journal, December I, 1897.

58 DISEASES OF THE HEART AND PBSICARDWM lfa9a

the fragments from the valves and leads to embolism. Aconite is of
groat value to slow and steady the heart. In this and other respects the
treatment is mucU like thai of pericarditia (g 38), though the local treatment
has less eSect in endocarditis. Stimulants and digitalis are indicated only
if the heart's sction is very weak and irregular, and they should be given
with great caution, for fear of stimulating the heart too much and promotiitf^
embolism.

3 89ii. Ulcnatin or KtUgnuit Sndocudllii (SynoDymn — Infective Endocarditis).
— In this form the endocardium is much moie Eeriousl; affected, for there is mor^
deetniction of the valves and adjoining surfaces, so thtA large ulcers may be produced,
and the valves may be periorated, or even completely disappear. The vegetations,
too, are much larger.

It seema doubtful if the disease ever occurs as a primary affection, but it ii rather
a septicnmia or blood infection, in which the heart valves form a nidu« for the oiccu-
lating orgMtisma. The micio-organisms most commonly found are staphyl-Kocci and

Fig. 16.— Chart of Hallgnaut or Uleerattve BndoeardlUi.

atroptococci, pneumococci, and, more rarely, gonococci, bacilli ooli communes, typhoid
and influenza bacilli. It is, therefore, usually a complication of such dieeaacs aa
pneumonia, eiysipelaa, acplic wounds, abscesses, meningitis, gonorrhoea, dysentery,
or puerporal fever. It is met with more isiely after chorea, scarlatina, and rheuma-
tism, diseaaea in which simple endocarditis is so common ; and with extreme rarity
after tubeniulosis, diphtheria, and variola. Thtre is a marked piedisposition for the
disease to attack a heart which ie already the seat of chrooio endocarditis. (1) Th«
Contlitutitmal Syinptmn' vary considerahly, but are usually grave, rompHsing intenso
anEsmia, great prostration, and, in (n) the Typhoid caritty, the early supervention of
somnolence and muttering delirium. In (bj the Septic varidy (such as arises wiUi
acuta necrosis, the puerperium, or an external wound) the mind remains quite clear
to the end. but rigors and sweats are prominent, simulating ague or pyemia. The
spleen is usually enlarged, and petechial rashes are fairly Iniquent. The fever is high.

§ 40 ] MALIGNANT ENDOCARDITIS— TAOH YOARDIA 59

and may be continuous, but it more often runs an irregularly intermittent course,
which may extend over weeks or months. (2) Generally there is a Cardiac Murmur,
but a careful examination may be necessary, and occasionally — in cases free from old
valvular mischief — ^there is none ; so that theoccurrence of embolism may be the first
symptom to draw attention to the heart. (3) The Emboli may be simple blockings
of an artery, as in simple endocarditis, but they may become abscesses, which in turn
form sources of septic infection in the lung and elsewhere (Symptoms of Embolism,
see p. 56).

Course and Varieties. — ^The severity and duration of the disease vary widely.
Those cases coming on without previous cardiac mischief usually run a rapid and
acute course of five or six weeks. Varieties (a) and (6) vide supra, (c) The Cardiac
group (Bramwell) — ^those in which previous chronic valve disease exists — run a
prolon^d course of many months, up to a year or more ; rigors are often absent,
and it may be very difficult from the symptoms to decide if malignant endocarditis
is present or not. Between these extremes every grade is met with, but in the
end the disease is almost always fatal, (d) There are certain ah?rrant forms marked
by the predominance of such symptoms as jaundice, diarrhoea, parotitis, profuse
sweatings, various eruptions, or pyrexia of a continued type.

The Diagnosis from enteric, ague, acute miliary tuberculosis, acute lymphadenoma,
cerebro-spinal meningitis, and pysamia may be very difficult. An intermitting or
remittent temperature, rigors, emboli, peteohise, pallor of the face, and the var3ring
character of a cardiac murmur, are points in favour of ulcerative endocarditis. In
enierie the onset of the fever is gradual ; rigors and sweats rare or absent. The
ineffioaoy of quinine serves to differentiate it from ague. Local lung symptoms aid
the diagnosis of acute miliary tuberculosis. In pycsmia the cause is probably apparent,
and the rigors and sweatings are more frequent.

Treatment must be conducted on the same general lines as that of the benign variety
{q.v.), the precautions as to rest and stimulants applying, if possible, with greater
force. On tiieoretioal grounds it would be well to administer abundance of nutriment
and to try antiseptic remedies, such as quinine in full doses, antipyrin, antifebrin,
sulphocarbolates, guaiacol, and the like. The recognition of the fact that malignant
endocarditis is part of a septicsamia has led to more rational methods of treatment.
Cases of recovery by the use of antistreptococcic serum have been reported, but this
treatment has been generally disappointing, because of the large number of different
organisms which may cause the disease. The method introduced by Sir Almroth
Wright promises greater success, and some encouraging results have been attained by
its use. A culture of the infecting micro-organism is obtained from the patient's
blood, and horn it a vaccine is prepared. This is injected subcutaneously, the fre-
quency and dosage being controlled by estimating the opsonic index (Chapter XX. ).

There are two other, rarer, heart disorders which arise very suddenly,
and in these also the area of prsdcordial dnlness is not necessarily increased
— (in.) Paroxysmal Tachycardia, and (IV.) Angina Pectoris. These are
paroxysmal disorders without Elevation op Temperature.

§ 40. The jHiHent is suddenly seized with an attach of " jxUpitatian,'^ but
WITHOUT ANY DEFINITE PAIN IN THE CHEST — the disease is probaUf/
Paroxysmal Tachycardla (Neuro-palpitation).

(m.) Paroxysmal Tachycardia (idiopathic tachycardia, heart hurry, neuro- palpita-
tion, hysterical or nervous palpitation) is a term somewhat loosely applied to signify
a quick pulse, but, unlike bradycardia (slow-pulse), which has no meaning in itself,
the term ** tachycardia '* should only be employed to denote a special disease with
characteristic symptoms. Tachycardia proper, or paroxysmal tachycardia, is now a
recognised, though not very common, condition. It consists of a series of paroxysms,
coming on at intervals, with abrupt onset, lasting for a few minutes to several hours,
during which the rapidity of the pulse may amount to 200. It returns to a normal
rate just as abruptly as it started. Sometimes there is no subjective distress, but it
may be accompanied by a sense of constriction and suffocation, and the attack may

60 DISEASES OF THE HEART AND PERICARDIUM [ § 40

commence with a " sinking ** in the epigastrium. The face wears an anxious, terrified
look, and the patient may complain of ** flushing " of the general surface, with a feeling
of heat or " pins and needles " all over. This is usually followed, in all the cases
which I have seen, by pallor of the skin, a feeling of coldness of the extremities, with
tremor, or actual shivering. Such are the symptoms of a typical attack of Paroxysmal
Tachycardia, though the details may vary in dififeient patients. The attacks return
at varying intervals (days, weeks, or months), and are often determined by some
emotioal cause. ^

The Diagnosis from Angina Pectoris is given under that affection (§41).

Causation, — ^The disease is not limited to any special period of life in women ; it
may occur at any time from childhood to late middle age. In men it occurs usually
from fifteen to twenty-five years. No cause has been discovered, either in the heart
or other organs. In some cases the disease appears to be due to a disordered nervous
condition, either in the vagus or in the sympathetic, probably the former.^ An
attack may be brought on by mental or physical strain in those who are subject to
the disease. It may also be associated with hysteria ; the case I have narrated in
the footnote below was associated with many of the symptoms of that malady, and I
have known many other cases of tachycardia similarly associated. Compare also 5,
p. 61 (angina vaso-motoria). All the facts point to that form of the disorder
being an angioneurosis in which dilatation of the peripheral vessels suddenly occurs
under any abnormal strain. The polygraph recoids show two forms, one in which
the auricle beat is in normal position ; and one in which the auricular beat is
absent.

The Prognosis depends upon the frequency and duration of the attacks. The
conditio^, it would seem, can only be temporarily cured, though patients may live
for years. Br. H. C. Wood cites a case of a physician who suffered from it for forty-
three years. In the emotional variety recurrence of the attacks may be prevented
by avoiding the cause.

Treatment. — For an (Utack a full dose of digitalis in brandy and water is recom-
mended by some ; others recommend that the patient should forcibly close the
glottis and make a strong expiratory effort. Some patients obtain relief by strong
coffee or by iced water. Ammoniated tincture of valerian is very efficacious. Tincture
of sumbul, spirit of ether and of chloroform, sal volatile, and bromide of ammonium,
are also useful. A seizure of this kind may frequently be cut short or averted if the
patient can be induced to take some form of muscular exercise. Electrical stimulation
of or pressure upon the vagus in the neck, may arrest an attack.

In the intervals, regular occupation, the avoidance of the various causes which
are known to produce an attack, and attention to the general health, are advisable.
Sodium salicylate and bromides relieved a case of Sir Clifford AUbutt's, with gouty
family history. Probably bromide in some form is the most useful medicine.

^ The following may be quoted by way of illustration. In May, 1887, 1 was hastily
summoned to one of the nurses in the Infirmary, who had, two hours before, witnessed
for the first time in her life the death of a patient. She was a healthy youns woman
of twenty- five, in whom there had been previously no manifestations of hysteria.
The solemnity of the scene in which she had just played her part was well calculated
to have a very powerful emotional effect upon a novice, and she thereupon burst
into a flood of tears. From this she recovered sufficiently to play the organ for
prayers, but in the middle of the service she was seized with violent palpitation of the
heart, accompanied by a pain over the apex, a sensation of " pins and needles " down
the arms and legs, and a sense of impending suffocation. I found her in a state of
collapse and general tremor, and unable to remember what had happened. The
pulse was beating 120 per minute, respiration sighing, and the surface of the body
and limbs pale, cold, and covered with a profuse cold perspiration, having previously
been, I was told, suffused with marked general redness. There were no physical signs
of cardiac or other visceral disease. I administered 30 trains of bromide of poti^h,
16 erains of chloral, and 3 m Hq. atrychninae. She gradually rallied, and presently
sank to sleep, and the next morning she was herself again.

^ The clinical phenomena are best explained by the hypothesis that there is a
sudden lowering of the general blood-pressure, due to an equally sudden and wide-
spread paralysis of the vaso- motor nerves of the peripheral arteries.

S41] ANGINA PECTORIS 61

IV. The piUienty probaUy a maley at or 'past middle Ufe, is suddenly seized
with a severe " constricting " pain in the chest, accompanied by a sense
of suffocation — the disease is Angina Pectoris.

§ 41. Angina Pectorii is a paroxysmal affection in which the attacks consist of
severe cramp-like pain in the region of the heart, attended by a sense of suffoca-
tion and impending death. The classical and severe tjrpe of this affection is,
happily, very rare, but milder attacks, known as ** pseudo-angina '* are not un-
common.

Symptoms, — (1) An attack comes on quite suddenly, often after some exertion (at
any rate, on the first occasion), and consists of acute pain in the h<rart, which radiates
down the arms, especially the left arm. The site of the pain, Mackenzie points out,
is over the distribution of the four upper dorsal nerves, and across the chest ; the skin
may be hyperalgesic over this area. The face is expressive of the torture which the
patient suffers, and at first is of a deadly pallor.^ The limbs also are pale, benumbed
and often covered by a clammy perspiration. The patient is restless in his endeavours
to assume a position of comfort. The sense of suffocation, of bodily discomfort, con-
striction of the chest, and of impending dissolution is extreme. The attack lasts
from a few minutes to one or two hours, or more, and is liable to be aggravated if the
patient ventures to move from the position of ease which he may have assumed.
In a certain proportion of the cases death closes the scene. (2) The heart's action,
when examined, is sometimes found to be unaltered, though palpitation may be com-
plained of. In those cases which I have observed during the attack, the pulse was
notably slow and feeble ; and this is generally a marked feature in cases about to be
fatal. It may be irregular, and in some cases it is increased in rapidity. There may
be no murmur or physical signs of any kind referable to the heart, but more usually
some form of aortic valvular mischief is present (see Etiology, p. 62). (3) The mind
remains clear throughout, so that the patient appreciates fully the horror of his
position. Many cases are accompanied or succeeded by a profuse flow of urine ;
others by profuse perspiration. Among the less frequent symptoms are tonic muscular
spasms, convulsions, and vomiting. The limbs and other parts which were the seat
of pain may afterwards feel " numbed." (4) In by far the larger number of cases
the patients are of the male sex, and advanced in life. Out of 88 cases collected by
Sir John Forbes, 80 were men, and 72 of these were over fifty years of age. The
disease also appears to affect by preference persons among the wealthier classes of
society, and, for some inexplicable reason, as Fagge and Pye-Smith point out, persons
who have been possessed of unusual mental capacity.

Varieties, — 1. When discoverable cardiac lesions are present, the disease is known
as Symptomatic Angina Pectoris,

2. Idiopathic Angina Pectoris is that form in which no such organic cause can be
detected.

3. Pseudo-Angina Pectoris is a term loosely employed to designate any attack of
cardiac pain and palpitation — e,g,, the anginoid attacks accompanying flatulent dis-
tension of the stomach. Walshe and others describe under this term a minor form of
attack of frequent occurrence, consisting of more or less severe pain, referred to the
region of the heart, with palpitation, ** coming on either without cause or after
exertion, or through overeating, or indigestion, or flatulent distension of the stomach,
or a variety of other fimctional disturbances."^

4. Hystarical Angina Pectoris is a term sometimes empbyed erroneously for the
condition described under Neuro-palpitation or Paroxysmal Tachycardia (§ 40).

5. Angina Vaso-motoria is a term applied by Nothnagel to oases somewhat resembling
true angina pectoris, excepting that the symptoms of vaso-motor disturbance — ^pallor

^ This pallor of the surface is generally succeeded by a reddish, or sometimes
cyanotic, tint of the same parts, as I have several times observed in patients at the
Infirmary during the attacks. [Trousseau (Clin. Lect. New Syd. Soc, vol. iii.) and
Anstie (Trans. (3in. Soc., vol. iiL) have also noted this stage.] The succeeding stage
of cyanosis is due to the paraljrtio dilatation which sometimes follows the spasm of
fcho ftfteriolofi.

2 Walshe, " Diseases of the Heart," fourth edition, p. 209.

62 DISEASES OF TUE HEART AND PERICARDIUM [ § 41

followed by cyanosis, coldness, and numbness of the extremities — predominate over
the symptoms referable to the chest. ^

Diagnosis. — (1) It is important to distinguish the different forms of '' anginoid
attack " grouped under ** Pseudo-Angina Pectoris " from true angina. Among the
features which sometimes enable us to distinguish pseudo-angina from the graver
form of disease are the following : (L) They come on at any time of life, whereas true
angina is confined to persons of the male sex over forty- five years of age ; (ii.) they may
occur in either sex, the hysterical form being specially liable to afifect young women ;
(iii.) thoy may come on spontaneously, without previous exertion (though this is not
constant) ; (iv.) they often appear after meals, and are nearly always associated with
some gastric derangement, such as dilated stomach, flatulence ; (v.) the pulse of pseudo-
angina is usually rapid and regular, never slow ; and the sounds and boundaries of
the heart are normal. Nevertheless, pseudo-angina, like true angina, may or may not
be associated with cardiac lesions. (2) Attacks of Paroxysmal Tachycardia are not
difficult to differentiate from true angina, on account of the great rapidity and the
regularity of the pulse, and the normal arterial tension. (3) Biliary Colic has occasion-
ally to be diagnosed from angina, but here the patient advanced in years is usually of
the female sex, and the condition is speedily followed by jaundice. (4) The diagnosis
from the other causes of prsecordial pain has already been given (§ 23).

Etiology. — ^The immediate cause of an attack is usually some undue exertion.
After death it is said that no structural disease of the heart and arteries may be
found, although far more frequently the heart walls are found to be degenerated, flabby,
or fatty, with or without other changes in the cardio- vascular system.

The clinical and anatomical antecedents of angina are the following: (1) Fatty,
or fibroid, or granular degeneration of the heart muscle is said to be the most frequent.
(2) Aortic valvular disease, especially stenosis ; mitral disease is rare. (3) Advanced
atheroma or calcification of the aorta. (4) Aneurysm or dilatation of the aorta,
especially of the root within the pericardial sac. (5) Atheroma of the coronary
arteries, calcification, or some other disease of these structures ; and this may in some
cases lead to embolism or thrombosis, and thus to a more or less localised degeneration
of the cardiac muscle (Kemig). (6) Arterial sclerosis (using that term in its widest
bense to indicate any thickening and rigidity of the arterial walls). (7) Gumma of
the heart wall, in wMch circumstances the patient may be young. ^

Angina Pectoris has been regarded as the result of disease of the coronary arteries,
but it is now generally believed to bo due to a sudden demand for increased effort on
the part of a damaged heart. In, at any rate, a certain proportion of cases this sudden
demand consists of an abrupt increase in the peripheral resistance by contraction of the
peripheral arterioles. It appears that for the production of the attacks of angina the
combination of these two factors is necessary. Neither of these can alone produce a
paroxysm ; for, as Bioadbent (*' Heart Disease ") points out, high arterial tension is
extremely common, alone ; so also is a degenerated heart wall — yet angina is raro.
When, however, the two are present in combination, a third or determining cause
{e.g., some unusual exertion, or a further increase in the blood-pressure), supervening
suddenly, may produce an attack of angina.

Prognosis. — True angina is an extremely serious condition. The patient may die
in a paroxysm. The attacks are sure to return, though this may not happen for some
years. When there is no marked arte rio- sclerosis and there is response to treatment.

^ Dr. James Mackenzie considers this is a condition of true angina occurring in sub-
jects of low blood-pressure who are liable to feel the cold.

^ Dr. Sidney Phillips {Lancet, 1897, vol. i., p. 223) has collected a valuable series of
cases, and from these it would appear that, if small and situated elsewhere than in
the loft ventricle, a gumma of the heart may give rise to no svmptoms, until by its
growth it produces sudden death. It is not, therefore, possible to diagnose cardiac
syphilis with certainty. Its existence, however, may be suspected in presence of
angina pectoris and a rapid, irregular pulse, especially if these occur in a person under
middle age, and if no other cause for these symptoms can be made out. If these be
present, even in a slight degree, in syphilitic persons, they should be regarded with
grave apprehension ; and the disappearance of these symptoms under antisyphilitio
treatment renders the diagnubis highly probable.

§ 48 ] ANOINA PECTOEIS—CHBONIC DISEASES 63

the outlook is good. In women who have had long strain, as in nursing sick relatives,
both mental and physical exertion must be prohibited, and in such oases complete
recovery is usual. The existence of a cardio-valvular lesion does not materially
modify the prognosis ; the condition of the cardiac wall is our best guide to the prob-
able oouise of a case (§ 50).

Treaimenl. — (a) For the Attacks. — ^Amyl nitrite, 3 to 5 minims, inhaled, generally
gives prompt relief, a method of treatment for which we are indebted to Sir Lauder
Bnmton. Sufferers should carry about with them glass capsules containing this
quantity, which can be broken into the handkerchief. ^ The remedy hastens the advent
of the second stage of arterial dilatation, and the attack passes off. For a more lasting
effect, nitroglycerine may be given internally, -j Jg drop every one to four hours, in
tabloids, pushed to tolerance to A drop. All the nitrites have a similar action in
dilating the peripheral arteries ; and lately advantc^ges have been claimed for erythrol-
totra-nitrate, in that its effects are more permanent, 1 grain administered in 1 drachm
of absolute alcohol, suitably diluted, being said to have effects lasting four to five
hours. It is reported to have relieved cases in which other remedies have failed. A
hypodermic injection of a full dose of morphia, if the last-named remedies are not at
huid, generally gives some relief ; and in very severe cases chloroform, inhaled to
complete ansBsthesia, has been recommended. If this be combined with a dose of
morphia, ite effects become more prolonged. Hot drinks and large doses of oxygen are
useful. In some cases of ** Angina Vaso-motoria," warm baths givo great relief. I
have not tried this treatment in cases of true angina, but, judging from the good
offiects I have observed in other conditions of vascular spasm, this method of treatment
would be very efficacious in cases where movement is not harmful to the patient.
Mustard plasters and warm fomentations to the epigastrium may be tried, either
during or between the attacks. In two cases of somewhat severe pseudo-angina I
found that the following draught, carried by the sufferer in his pocket, and taken at
the outeet of an attack, was attended by prompt relief : Tinct. lobeliae seth., tnxx. ;
spiritus otheris, inxx. ; liquoris morphinse, inxx. ; aquae chloroformi, ^i*

(6) Between the Attacks, — It follows from the above remarks on the etiology that the
indications for treatment lie in two directions — to relieve excessive tension or any
tendency to vascular sjM^m, and, if possible, to restore the damaged heart. If the
main element of the case is cardiac onfeeblement, this should receive our special
attention, on the lines mentioned elsewhere (Treatment of Cardiac Valvular Disease).
If, on the other hand, the peripheral resistance is excessive, our treatment should be
directed to reduce it. The pulse should be examined many times, and under different
conditions, during the day, and if the tension is very high, much may be done, even
though the arteries be diseased (§ 61, High Tension). Erythrol-tetra-nitrate and nitro-
glycerine are hero again valuable remedies, not only to relieve, but to prevent the
occurrence of the attacks, and these may be combined with various cardiac tonics,
such as iron, nux vomica, and especially arsenic. Digitalis and stimulants may be
administered on the same principles as in cardiac valvular disease. To insure rest at
night chloral, gr. v., may be given.

Much may be done by regulating the mode of life, and avoiding those things which are
known by experience to induce the seizures. Repose of mind and body must be strictly
enforced. Other determining causes met with are exposure to cold, indigestion, dilatation
of the stomach by too heavy meals, and a sudden alteration of posture by the patient.
Such conditions must be avoided, as also any unnecessary or sudden exertion or emotion.

CHRONIC AFFECTIONS OF THE HEART AND PERICARDIUM.

§ 42. CAassifloatiim. — Chronic Disorders of the heart and pericardium
may follow an acute attack of the conditions described in the previous
sections, as, for instance, when chronic valvular disease dates from an
acute endocarditis which has complicated rheumatic fever or scarlatina
in early life. But a considerable proportion of the disorders which afiect

* This remedy seems to lose it« effect when preserved in the ordinary way in a bottle.

64 DISEASES OF THE HEART AND PERICARDIUM [ { 48

the heart are chronic from the beginning ; they start insidiously, and are
unaccompanied by any marked constitutional symptoms.

For clinical purposes, the chronic disorders of the heart and pericardium
may be divided into those attended by enlargement of the area of dulness
and those not necessarily so attended.

(a) Chronic Diseases attended by enlargement of the area of prsecordial

dulness.

I. Cardiac hypertrophy.
II. Cardiac dilatation.
III. Hydropericardium.

IV. Congenital heart disease (laie). Mem. Aneuiysm, and other
Mediastinal Tumours (see footnote to table on p. 50).

(b) Chronic Diseases not necessarily attended by enlargement of

the area of preecordial dulness, the diagnosis of which
may depend mainly on auscultation.

I. Valvular disease.
II. Fatty or fibroid heart.

It is important to bear in mind that valvular disease, though not per se
giving rise to an enlarged area of prsecordial dulness, is so often associated
with hypertrophy or dilatation that it is usually attended by enlargement
of the prflBCordial dulness.

Method of Procedure. — It will be remembered that the routine examina-
tion of the heart consisted of (1) inspection ; (2) palpation ; (3) percussion
of the preecordial dulness ; and (4) auscultation. The student should bear
in mind the vekiioxxa faUacies which may give a false impression of cardiac
enlargement, and also those conditions, such as emphysema, which obscure
an enlarged heart (§ 33). If the area of dulness is not increased, turn
to §47.

Group A. — The patient complains of some of the subjective symptoms
pointing to chronic cardiac disorder^ and, on examination of the heart,
the area of dulness is found to be increased^ chiefly in the transverae
direction — the disease is probably Hypertrophy, Matation, or Hydro-
pericardium.

I. The APEX beats below Us normal ^position ; the impulse is forcible
and heaving ; on auscultation, the first soutid is dull and prolonged. There
is Hypertrophy op the Heart.

§ 43. Hypertrophy of the Heart, and the dilatation which not infre-
quently accompanies or follows it are certainly the commonest conditions
which produce an increased area of prsecordial dulness.

Cardiac Hypertrophy is an increase of the muscular substance of the heart,
and its weight, which is normally about 8^ ounces in women and 9 J ounces
in men, may be increased to 10 or 12 ounces, and on rare occasions to 15 or
20 oimces. Its signs are as follows : (1) The increase in the prflecordial

§ 48 1 SIGNS OF HYPERTROPHY OF THE HEART 65

dulness is in a transverse direction — towards the left if the left ventricle
be hypertrophied, towards the right if the right ventricle ; (2) the apex
beats below its normal position ; (3) the impulse is unduly forcible, heaving,
Of thrusting ; (4) on auscultation, the first sound is muffled, less audible,
and prolonged. The pulse is firm, strong, and bounding.

Sym^ptoms may be altogether wanting if the hypertrophy accurately
compensates for the obstruction in the circulation which has caused the
hypertrophy. The patient may, indeed, be unaware of any cardiac dis-
order. But generally, on inquiry, he will complain oi a " thumping " in
his chest and '* throbbing " in his head, occasionally of breathlessness and
precordial distress.

Etiology, — Hypertrophy, and the dilatation usually accompanying it, is
the result of some obstruction in the circulation, either in the lungs (such
as bronchitis and emphysema) or in the general circulation (such as cardiac
valvular disease, or arterial thickening). It is an illustration of the
physiological law that increased use leads to increased growth. The part
of the heart which chiefly undergoes hypertrophy will depend on the
position of the obstruction ; and the signs met with in addition to those
above mentioned will vary accordingly. Thus, there will be three sets of
symptoms : (a) Signs of hypertrophy of the heart ; (6) signs of enlarge-
ment of the cavity specially involved ; and (c) signs and symptoms of the
cause. The following causes will be more readily understood by consulting
Fig. 17 (p. 73), and it must be remembered that the enlargement is never
in actual practice strictly limited to one chamber of the heart.

(a) Hypertrophy op the Left Ventricle is indicated by enlargement
of the area of dulness, chiefly towards the left ; the apex beats below and
to the left of its normal position ; the pulse is strong unless modified by
the presence of a valvular lesion, and the carotids may be seen to pulsate.
This condition may arise under ten different causes :

(i.) MUral regurgitation, in which case there would be a systolic apical murmur, and
the other features given in § 47.

(iL) Aortic stenosis or regurgitation, which may be recognised by a basal murmur
of systolic or diastolic rhythm, and other characters given in § 47. The hypertrophy
resulting from regurgitation may be greater than that due to any other cause {cor
bovinum of the ancients). The heart may weigh in these cases 20 to 30 ounces, or
more. In roguigitant lesions a certain amount of dilatation always accompanies
hypertrophy, and the condition is then known as ** eccentric " hypertrophy. In
these cases the dilatation is compensatory, and produces no untoward symptoms.
True, or, as it is called, " concentric," hypertrophy, unaccompanied by any dilatation,
is only met with in aortic stenosis and Bright's disease.

(iii.) Aneurysm of the aortic arch, if unattended by valvular disease or renal mischief,
does not per se cause cardiac hypertrophy ; but it is nearly always so attended, and
thus becomes a fairly frequent cause of hypertrophy of the left ventricle. If the
aneurysm involves the first half of the areh. it produces marked physical signs ; if the
second or third part, pressure symptoms arise without signs (§ 53).

(iv.) Prolonged high Hood-pressure — and thus its numerous causes (§ 61) —
may lead to hypertrophy of the left ventricle. It is probably in this way that
chronic Bright's disease is so frequently accompanied by hypertrophy of the left
ventricle.

(v.) Widespread thickening of the peripheral arterioles is invariably followed sooner
or later by a certain degree of hypertrophy of the left ventricle (arterial sclerosis, § 67).

66 DISEASES OF THE HEART AND PERICARDIUM [§48

(vi.) Disturbed innervation, such as attends the " irri table heart," Graves' disease, and
nouTo-palpitation, in time results in moderate hypertrophy, chiefly of the left ventricle.

(vii.) Pericardial adhesions, unless they are few or filamentous, or unless there is
universal internal adhesion, so that the heart cannot expand, is a doubtful cause.

(viii.) Excessive, muscvlar exercise, whether athletic or laborious, may produce
liypertrophy, and in support of this statement it may be mentioned that the normal
incr&ase with age is more noticeable in men than in women.

(ix.) Cardiac fibrosis (sclerotic myocarditis) is a i-are condition, which may be
associated with a certain amount of hypertrophy.

(x.) Increased density of the Uood is a cause of hypertrophy which is not mentioned
among the lists usually given ui textbooks, but which, nevertheless, must be of con-
siderable potency. It is estimated that 99 per cent, of the work done by the heart is
employed in overcoming the resistance due to capillarity in the arteries and capillaries,
and it follows, almost of necessity, that if the density of their fluid contents be increased ,
the resistance will be increased proportionately.

Obscure Causes, — If in a given case of cardiac hypertrophy careful
examination reveals no valvular mischief, and no obvious cause can be
made out, the physician should always suspect obscure aortic aneurysm,
OBSCURE RENAL DISEASE, or widespread arterial thickening.

(6) Hypertrophy of the Right Ventricle is indicated by enlarge-
ment of the area of dulness to the right ; throbbing and pulsation in the
lower left intercostal spaces and epigastrium (and if accompanied by
dilatation, pulsation also in the veins of the neck) ; a violent but more
diffuse cardiac impulse ; and, on auscultation, accentuation of the second
sound over the pulmonary valves. The degree of hypertrophy present may
he measured by the degree of the second and fourth of these symptoms : in tliia
way we measure the efficiency of compensation (§ 50).

It may be due to three important causes :

(i.) Pulmonary diseases attended by obstruction in the pulmonary circulation, of
which bronchitis and emphysema are certainly the most frequent. This combination,
a very common one, is identified by a history or evidence of lung mischief (§ 93).

(ii.) Mitral stenosis is the next most common cause, and should be borne in mind
even in the absence of a presystolic murmur (§ 47).

(iii.) Mitral regurgitation is followed by hypertrophy of the right ventricle, due to
the congestion of the pulmonary circulation.

(c) Hypertrophy of the Left Auricle is always attended by dilata-
tion. It is a difficult condition to detect, because the palpable and visible
pulsation in the third left interspace, when present, though due to this
cause, may admit of other explanations.

It may arise in mitral regurgitation, but its chief cause is mitral stenosis. In the
latter condition, palpation generally reveals a thrill over the apex, and careful auscul-
tation may detect the presystolic or mid-diastolic murmur (§ 47).

Hypertrophy of the Right Auricle is not recognisable clinically.

(d) Extreme Hypertrophy op Both Auricles and Ventricles arises
in congenital heart disease, but may be confined to the right side, since the
valvular lesions are mostly on that side.

Prognosis and Treatment. — Cardiac Hypertrophy is in itself essentially
a conservative process for some condition which causes obsti-uction in the
ciivulation. It is Nature's method of compensating for the obstruction,
and it is well to promote it up to a certain point.

§44] CAUSES OF HYPERTROPHY OF THE HEART 67

1. I/the cause he removable, the prognosis is favourable. Our treatment
in such cases should therefore be directed to the removal of the cause —
e.g,, high blood-pressure, which can be reduced.

2. If the cause be fwt removaUey the prognosis of the case depends on
our being able first to maintain the compensatory hypertrophy, and,
secondly, to relieve the heart of part of its work, so that the hypertrophy
does not go beyond what is necessary. To accomplish the first, we should
endeavour to promote the general nutrition by tonics and hygienic
measures, and by regulating the bowels with mild saline laxatives, and
similar remedies. In order to relieve the heart of part of its work, and to
aid the systemic circulation, baths, massage, passive and active move-
ments, are of the greatest use (see § 51).

3. The existence of cardiac hypertrophy adds an element of risk to a
person's life in three ways. In the first place, hypertrophy infallibly
indicates that there is obstruction somewhere in the circulation, and
this, whatever it be, is in itself an injury to health, and may shorten life.
Secondly, a far more important consideration is the increased liability to
cerebral hsBmorrhage, and vascular rupture elsewhere. Thirdly, high
arterial tension is an almost invariable accompaniment of cardiac hyper-
trophy, and this causes a continual strain upon the peripheral vessels,
which results first in arterial hyperrayotrophy and later in arterial sclerosis,
the serious consequences of which are indicated elsewhere (§ G7).

II. The area of dulness is increased ; the posiUon of the apex-beat is
INDEFINITE ; the impulse is diffuse and toavy ; on auscultation^ the first sound
is short and sharp. The disease is Cardiac Dilatation.

§ 4/L Cardiac Dilatation (one form of " Cardiac failure ") is an indica-
tion that the heart is " failing " to keep pace with the extra demand
made upon it, that the reserve power of the muscle wall is becoming spent.
The heart as a whole possesses a certain amount of reserve power, but
certain foci of muscle fibres may show signs of exhaustion before others
(§§ 50 and 58). In ordinary circumstances the heart first hypertrophies,
then dilates. Hypertrophy and dilatation are usually associated, but
if the nutrition of the body or of the heart is faulty, the heart begins to
dilate from the outset, without any preliminary hypertrophy.

The Physical Signs of cardiac dilatation resemble those of hypertrophy
in several ways, and, like it, (1) the area of dulness is increased chiefly in
a transverse direction, to the right or to the left, according to the side of
the heart which is dilated. But there are three important features
specially belonging to dilatation : (2) The cardiac impulse is wavy and
diffuse, and is displaced outwards rather than downwards ; it may be so
feeble as to be hardly perceptible. (3) On auscultation, the first sound
at the apex is clear and sharp, resembling the normal second sound in
character. Murmurs may be present from coexisting valvular disease,
but a systolic murmur — the " murmur of dilatation " — may sometimes
be heard apart from actual valvular disease, because the auriculo-ven-

DISEASES OF THE HEABT AND TEEICARDIUM

[§44

tricular orifices, by reason of the dilatation, allow a reflux of the blood.
(4) The pulse is feeble, rapid, irregular, and sometimes intermittent (see
also Table III.).

Table III. — Diagnosis of Typical Cabdiac Hypertrophy from

Typical Dilatation.

Apex-Beat and

Impulse : Displaced

in Both.

J^ Forcible, heaving,
Pi tbiUBting ; below
S and to 1. of normal
"C (1. ventricle) ; in
^ epigastrium (r. ven-
S tricle).

Percussion.

(

L. V. : Area
increased trans-
versely to the 1.
IR. V. : Area
increased trans-
versely to the r.

Auscultation.

General Symptoms.

)

Sounds muffled,
prolonged, and
forcible.

(May be absent; or
symptoms of high blood -
pressure.

Feeble, irregular,
undulatory, difFuse.
If r. ventricle — pul-
sation in the epi-
gastrium and veins
of the neck.

(

L.V. : Area
increased trans-
versely to the 1.

B.V. : Area
increased trans-
versely to the r.

Systolic'^
murmur at
apex, at one
stage.

Systolic
murmur in
tricuspid
area, at one
stage.

o '

o »

» St
* ST

8*
P

r Dynpnoea, cough, cyan-
osis, and other signs of
lung congestion.

Dropsy, scanty higli-
coloured albuminous
urine, enlarged liver, as-
cites, and other signs of
congestion of organs.

Towards the end, when cardiac failure is extreme, foetal rhythm, gallop rh3rthiii,
and " delirium cordis " may occur. In foetal rhythm the long and short pauses are
almost identical, so that the first and second sounds can scarcely be distinguished ;
in gallop rhythm there is rapidity of action, together with a distinctly reduplicated
second sound. In delirium cordis the heart is so rapid and so irregular that it is
practically impossible to make out the relations of sounds and murmurs.

It is, however, by the presence of certain symptoms that the existence
of cardiac dilatation (or failure of compensation) generally becomes
manifest. In hypertrophy, as we have seen, there may be no symptoms
at all ; but with dilatation the patient complains of : (1) Heart symptoms,
such as breathlessness on little or no exertion, palpitation, and prsBcordial
distress. (2) There may also arise a number of symptoms referable to other
parts, in consequence of the delay in the circulation, such as anasarca,
ascites, and symptoms of congestion of the lungs, liver, and kidneys.
These will be described under Cardiac Valvular Disease, where the means of
detecting which cavity is chiefly involved are also given (see also Table III.).

The Causes of Cardiac Dilaialion are of extreme importance as bearing
on the prognosis and treatment of cardiac valvular disease and other
circulatory disorders. The clinical conditions which produce dilatation
are practically identical with those which produce cardiac hypertrophy
(§ 43), when they are persistent and are associated with some condition
which impairs the nutrition of the heart (see (6) below). Undoubtedly the
two commonest causes of cardiac hypertrophy and dilatation are Cardiac
Valvular Disease and Chronic Bronchitis with Emphysema, and
these are the possibilities which should first suggest themselves to the
mind in a case where dilatation is evident. The former will be fullv
discussed in the following section.

§ 45 ] CARDIAC DILATATION^HYDROPERICABDIUM 69

Chronic Bronchitis^ with its usual accompaniment of Emphysema, pro-
duces in time a dilated Right Ventricle. This latter is recognised by two
very characteristic local signs, in addition to the breathlessness, etc.,
above mentioned — viz. : (i.) epigastric pulsation ; and (ii.) pulsation
in the jugular veins. The clinical picture presented by this frequent
pathological combination is very characteristic — the florid face and
plethoric build ; the easily excited breathlessness and constantly recurring
cough, enable us to recognise the condition almost at a glance. The sub-
ject will be more fully discussed under Cardiac Valvular Disease (§ 47).

The essential or pathological causes of Dilatation may be arranged under four
headings :

(a) Any condition which persistently prevents the complete emptying of the cavities
of the heart (see Causes of Hypertrophy) will produce compensatory hypertrophy with
dilatation, which will be exactly proportional to the increased resistance in the circula*
tion, provided none of the circumstances mentioned under (6), (c), or {d) beloW are
also present. If any of these circumstances aro in operation, dilatation or failure
may be initiated without previous or accompanying hypertrophy. Moreover, the
supervention of any of these in the course of a cardiac case may at once disturb a well-
balanced compensatory hypertrophy, and serious symptoms may immediately appear.

(6) Any failure of general ntUrition, or vitality, may entail a weakened cardiac wall,
which will perhaps yield even under normal circulatory conditions. Such, for instance ,
may be caused by exposure, insufficient food, alcoholic excesses, old age, various
fevers (especially rheumatic fever, typhus, typhoid, and malaria), various blood
conditions (such as pernicious anaemia, scurvy, chlorosis, leukemia, etc.), and cachectic
conditions (such as syphilis, tubercle, and cancer). See Causes of Pyrexia and of
Anaomia (Chapters XV. and XVI.).

(c) Local impairment of the mttrition of the heart wM may result in dilatation without
hypertrophy, even with normal circulatory resistance. Myocarditis, for instance, and
the conditions which accompany peri- and endo-caiditis (which lejkd sometimes to
acute dilatation) ; or the more gradual degenerations which ensue on sclerosis and other
diseases of the coronary arteries ; or fibroid and other degenerations of the cardiac
wall (see Fatty Heart). Prolonged fatigue may also act locally by overtaxing the
heart muscle. Any of those may upset the balance of a well-adjusted hypertrophy.

{d) Any sudden strain on an apparently normal heart may produce acute dilatation.
Thus, severe and sudden grief, fright, or anxiety may damage the heart through its
nervous apparatus, and severe muscular exertion in athletes or others who have not
had any previous training may cause the heart to give way and dilate. Instances of
the latter are met with in hill-climbers who are *' out of form," and others who take
sudden and unaccustomed exercise. Breathlessness may date from incidents of this
kind, from which the patient may never, or only with difficulty, recover.

The Prognosis and Treatment of Cardiac Dilatation are fully dealt with under Cardiac
Valvular Disease (§ 47).

III. The area of dulness is increased upwards, atbd its shape is pyra-
midal, with the point upioards ; the apex-beat is raised, and the impulse is
weak and undulatory ; on auscuUation, the sounds are feeble. The disease
is Hydropericardium.

§ 45. HydroperioArdinm is a chronic effusion of fluid into the pericardium. (1) The
shape of the dulness is very characteristic, being pyramidal, with the narrow end
upwards. (2) The apex of the heart is raised, and to the right of its normal position,
because the roof of the pericardium is raised by the fluid, and takes the heart with it.
(3) For the same reason, the left margin of praecordial dulness extends beyond the apex-
beat. (4) On auscultation, the heart sounds are distant and muffled. There may be
irregularity and rapidity of the pulse, and difficulty of breathing from the impeded
action of the heart and lungs.

7) DISEASES OF THE HEART AND PERICARDIUM [ § 46

Etiology. — Chronic effusion into the pericardium may originate in one of three ways.

(1 ) Ab the result of Acute Pericarditis (§ 38), of which a history is generally obtainable,
but by no means always (see Latent Pericarditis, § 386). Most authors draw a dis-
tinction between chronic pericardial effusion of inflammatory origin and simple
dropsy of the pericardium (hydropericardium proper). But the physical signs are
practically indistinguishable ; for the diagnosis of the former we depend mainly on the
history of it having commenced as an acute affection, and on the absence of anasarca.

(2) True hydropericardium seldom occurs excepting as part of a general dropsy due
to renal or caidiao disease, and therefore the urine should be carefully examined.
In these circumstances the effusion gives relatively litUe inconvenience to the patient,
because it takes place so gradually that the parts have time to adapt themselves to
the stretching they undergo. (3) If hydropericardium be not preceded by pericarditis,
or be not part of a general dropsy, new growth or tubercle, although rare, should
always be suspected. In these circumstances, if a little fluid be withdrawn by a hypo-
dermic syringe (p. 54), it may be blood-stained (cancer), or contain bacilli (tubercle).

The Diagnosis from Cardiac Dilatation should be readily accomplished by the shape
of the dulness, which is square instead of pyramidal in dilatation ; and by the heart
sounds, which are clear and sharp in dilatation, muffled in effusion. X-ray examina-
tion is of assistance. Pleuritic effusion is attended by pulmonary symptoms.

The Prognosis of hydropericardium depends on it€ causation, being favourable in
Cause 1, adding only a little to the gravity of the primary malady in 2, and being
almost necessarily fatal in 3.

Treatment. — ^The treatment of inflammatory effusion is dealt with in § 38. If part
of a general dropsy, our efforts must be directed to this. Counter-irritants are some-
times useful. Paracentesis should not be considered imless the cardiac embarrassment
is very ui^nt, because of the danger of withdrawing a large amount of fluid suddenly
from the pericardial sac.

IV. The prcecordial percussion area is considerably and irregularly
increased : the impulse is forcible and heaving,

(a) The area is distorted at^ somewhat square ; on atiscuUationy there
is a loud murmur, probaUy loudest in the pulmonary area. The disease is
Congenital Heart Disease (see below).

(b) The UPPER PART of the area is ifhcreased transversely, and there is
dulness over the sternum — it is probably an Intrathoracic Tumour.
If on auscultation, the second sound at the base is reinforced and sharp, or
replaced by a diastolic murmur, it is probably Aneurysm of the first part of
the Arch of the Aorta (§ 53).

§ 46. Congenital Heart Disease is another chronic form of cardiac disorder attended
by increased praecordial dulness, but it is comparatively rare. There are three
cardinal signs produced by it : (1) The prsecordial dulness is very considerably in-
creased, the normal shape is distorted, and it may extend considerably beyond the right
border of the sternum, because the commonest form of the disease results in immense
hypertrophy and dilatation of the right ventricle. (2) Palpable and sometimes
visible pulsation over almost the whole of the cardiac area may often be detected for
the same reason. (3) A loud, rough systolic murmur can generally be heard, loudest
in the third or fourth interspace, close to the left of the sternum, and it is often easily
heard in the back. These signs in a child who has a tendency to cyanosis are almost
certainly due to cardiac malformation. (4) Dyspnoea is also fairly common, and may
be either persistent or paroxysmal. The condition, however, may remain latent for
many years, until exertion or some illness reveals its existence. The diagnosis is
sometimes a matter of difficulty. Other symptoms arise as the disease progresses —
thus, general cyanosis, reaching a very extreme degree ; coldness of the extremities ;
syncope and epileptiform attckcks ; a low temperature of the surface generally (because
the blood is iwor iu oxygen), although not of the interior of the body (Peacock) ;
drubpy occatiioually ; haemorrhages fix^m the lungs ; and symptums of congestion uf

§ 47 ] CONGENITAL HEART DISEASE— CARDIAC MURMURS 71

the other viscera. Dilatation of the conjunctival vessels is often observed, and
clubbing of the toe and finger ends. Headache is often present, and convulsions are
not unknown. Backwardness or precocity, and sometimes more grave mental
defects, become evident as the child grows older. It is important to remember that
very loud bruits may mean but slight abnormality, whilst very severe diesase may be
unaccompanied by even a slight murmur.

Etiology. — Congenital disease of the heart arises under two conditions : (1) Inflam-
matory affeciion-8 attacking the foetal heart in utero may lead to stenosis of the orifices,
almost invariably on the right side of the heart, which is in contradistinction to the
loft-sided lesions of extra-uterine life. (2) An arrest of the closure, which normally
takes place shortly after birth, of either the ductus arteriosus, foramen ovale, or the
ventricular septum. Whatever the cause, the commonest lesion is a narrowing of the
pulmonary artery or pulmonary valves,* which probably results in the venous blood
making its way through the foramen ovale or ventricular septum from the right to the
left side of the heart, the septum also deviating to the left. Stenosis of the aortic
orifice is much rarer, but in that case the arterial blood finds its way through the same
orifices from the left to the right side of the heart. In either case three events happen :

(1) Deficient oxygenation, and probably admixture of venous and arterial blood;

(2) the right ventricle takes an equal share with the left in the work of the heart, and
consequently it hyi:ortrophies and dilates ; and (3) the ductus arteriosus remains
patent, to compensate for the insufiiciont delivery of blood into the aorta or pulmonary
artery, as the c€kse may be. It is only occasionally possible to suggest the precise
nature of the lesion during life, but this, although it is a matter of great interest, is
not always of great moment.

Prognosis, — ^The condition may remain latent for many years, though f«w marked
cases survive to adult life. The prognosis is serious in proportion to the degree of
dyspnoea and cyanosis, pointing to deficient aeration of IJie blood, and in proportion
to the other symptoms of " cardiac failure " (§ 60).

The Treatment is the same as that of Cardiac Dilatation, bearing in mind that rest
IB of primary importance (§51).

We now turn to those Chronic Heart Diseases in which the area of
dulness is not necessarily increased, and which depend mainly on Auscul-
tation for their diagnosis (Table IV., p. 72).

V. On auscultation^ one or both of the heart sounds is heard to be acconi'
panied by a murmur, or bruit. Pericardial friction having been excluded,
the Valves of the heart are diseased — with certain exceptions or faUacies
{such as hwmic murmurs), which wiU be described,

§ 47. Chronic Endocarditis — Cardiac Valvular Disease — Cardiac Mur-
mors. — ^Disease of the valves of the heart is the commonest of all cardiac
disorders, and it is revealed on auscultation by the presence of a bruit or
murmur which is added to, or replaces, one or both of the heart sounds.

Method of Procedure, — In order to arrive at a diagnosis, it will be remem-
bered that four features must be carefully investigated in any given murmui
— namely, its rhythm, position, conduction and character (§ 34).
The last named is relatively least important. In order to be quite sure of
the rhythm of a bruit, it is often convenient to place the fingers on the
carotid artery whilst auscultating the chest.

^ Some observei's maintain that the primary mischief is always the non-closure of
the ductus arteriosus or foramen ovale or ventricular septum, narrowinff of the aorta
and pulmonary arteries being secondary. But the view above stated is the more
probable, because a small leakage through oiio of those orifices is a by no means infre-
quent occurrence without symptoms during life

DISEASES OF THE HEART AND PERICARDIUM

[§47

A cardiac murmur may arise in three ways. It may arise outside the
heart — e.g., from roughness of the pericardium ; it may be of h^mio or
FUNCTIONAL ORIGIN ; or it may arise within the heart from organic disease
OF THE VALVES (which chiefly concerns us now).

The characters of pericardial murmurs have already been given (§ 39) ;
and their diagnosis from endocardial murmurs (Table II., p. 55).

H^Mic, or functional, Murmurs are frequently heard in ansemia and in
soma other blood conditions (see Chapter XVI.). They are usually systolic
in time. They are rarely double, and never diastolic alone. They are
usually heard loudest in the pulmonary area. A single murmur of pre-
systolic or diastolic time is a certain indication of organic disease at one
of the cardiac orifices.

Organic Murmuis are those which are produced by organic disease of
the valves (cardio- valvular disease). Valvular disease may be due to
several lesions (§ 49), but the commonest one in early life is endocarditis
(acute or chronic), and in older persons chronic degenerative change.
The effect is a thickening or puckering of the valves and ring, which results
in one or both of two conditions : (a) Stenosis — i.e., a narrowing (orcvooi, to
contract) ^of the orifice, which prevents the blood flowing freely through it ;
or (6) Regurgitation, in which the valves are incompetent and allow a reflux
of the blood to take place from imperfect meeting and closure of the cusps.
The remote effect of these two conditions is practically the same — viz.,
a retardation or obstruction to the circulation of blood through that orifice.

It simplifies matters very much that cardio-valvular disease arising
after birth is practically confined to the left side of the heart — i.e., to the
mitral and aortic orifices. Thus it happens that there are four principal
cardiac lesions — Mitral Regurgitation, Mitral Stenosis, Aortic Re-
gurgitation, and Aortic Stenosis.

Table IV. — Differentiation of Cardiac Valvular Diseases.

Ausculta-
tion.

Systolic

murmur

conducted

into axilla.

Appear-
ance of
Patient.

Florid. '

Pulse.

Irregular,

rapid, and

compressible.

Other Symp
to the ]

Dropsy, v
' enlarged
' liver and
ascites, etc.,

ioms special
Disease.

' Mitral
(apical
murmurs).

' Regurgi-
tation.

with signs of
• congestion

■ ,

•

1 O

^ Stenosis.

Presystolic
murmur.

Patient
young.

Regular, small,
and moder-
ately firm.

Hcemopty. <^ «»^°*-
sis ; emboli, j

Aortic

(basal

murmurs). '

'Regurgi-
tation.

Diastolic

murmur

conducted

down
8ternum.

SaUow.

•• Water-
hammer,"
rapid and
compressible.

i Throbbing ^
1 of arteries
of neck,

with symp-
toms of
cerebral
1 aneemia and

^ Stenosis.^

Systolic

murmur

, conducted

into vessels

of the neck.

Heart
, lesion of

; the
aged.

Slow, regular,

smsdl and

hard.

No special j ^ta
symptoms, j a'^w^cks.

^ Real aortic stenosis is very rare, but atheromatous roughening is very common.

J 471 SYSTOLIC MUBUURS 73

The Btudent shuulcl otutly Fig. 10, p. 4JS, so as to thoroughly compreheaU thu various
eventa which oocur dniing one complete contnction and dilatation of the heart (a
,QB_ cardiac cycle). Uo should also liear iu mind that

the left Bide of the heart is behind the right, and
that the left ventricle comes neareat to the surface
only at the apex, immediately behind or just below
the fifth rib (Figs. 11 and 12, p. 46). He should
also remember that a cardiac murmur ia not pro-
duced in a diseased orifice, but by the eddies in
the blood-stream beyond. For theae leasous a
mununr is not always heard budest directly over
the orifice diaeaaed. The student may also consult
the accompanying diagram of the circulation.

Diagnosis of Cardiac Honnnn. — The first
thing to determine is whether a given
murmur is related to the first or second
sound of the heart — i.e., whether its rhythm
is systolic or diastolic — and this will form a
convenient basis of classification of cardiac
murmura.

A. Systfdic Hnnunn' — i.e., bruits added
to or replacing the first sound — may be
produced by the following causes, which are
mentioned more or leas in order of frequency :
Hiemic conditions (see above, and AntemJa,
§ 402), mitral regui^itation, aortic stenosis,
aortic aneurysm, tricuspid regurgitation,
pulmonary stenosis, congenital heart disease,
and cardio- pulmonary conditions.

1. In Mitral Bworgitatioa the systolic
murmur is characterised by (i.) being
loudest at the apex ; (ii.) being conducted to
the axilla, and also audible behind, at the
angle of the scapula ; and (iii.) owing to the
resulting hypertrophy of the left ventricle,
the apex is displaced downwards and out-
wards. There is accentuation of the second
sound in the pulmonary area, due to the
congestion in the pulmonary circulation.
The pulse is soft, there is a characteristic
florid physiognomy, and a tendency to
<EoS dropsy.

ng. 17. — Schems oltbe Clrculatloa of the Blood. — The anperiar aod inferior veiis cav»(6) bring
tha blood back from the organa and tluues into the right anrlcle (1). Theni^e It outei Into
the right Tsntriela i%), through the pnlmoiury artery 17) ir
lung) br th« pDlmaDarr veins <B|. It puaee tJuoiigb U: '
ftnd li diitribnted br meuu of the sorts (S. &) and thi
or tha body. Notlog that the blood trom the itom&cli
baton Joining the genenl circulation. (From Huxley

74 DISEASES OF THE HEART AND PERICARDIUM [ § 47

General Symptoms of Mitral Regurgitation arise when there is failing
compensation ; and two events take place, which, in order of occurrence,
are (1) dilatation of the left ventricle and pulmonary congestion ; and
(2) dilatation of the right ventricle,

1 . The symptoms of dilatation of the left ventricle have been already
mentioned (p. 67). Pulmonary congestion is revealed by laboured breath-
ing, cough, expectoration of mucus, sometimes tinged with blood, or actual
haemoptysis. The physical signs are abundant mucous rales, and some-
times scattered patches of dulness at one or both bases. Pulmonary
apoplexy may be suspected by sudden increase of dyspnoea, accompanied
by continuous hsemoptysis.

2. Dilatation of the right ventricle, consequent on the congestion of the
pulmonary circulation, sooner or later produces the following symptoms
and conditions :

(i.) A tricuspid bruit is sometimes heard (see below, p. 75).

(ii.) Pulsation in the epigastrium and in the veins of the neck.

(iii.) Dropsy, which indicates congestion of the whole venous system.
Cardiac dropsy starts and predominates in the legs or the hack, whichever
may happen to have been in the most dependent position. The skin is
tense, and is very liable to be attacked by erythematous, erysipelatous,
and inflammatory conditions (cellulitis, ulcer, etc.). Ascites in varying
amoimt is generally present. It is often an early and prominent sign in
mitral stenosis. Cyanosis and a general lividity of the surface are conse-
quences of the same venous stasis. A case of mitral disease, therefore,
presents a marked contrast to one of aortic disease, where the countenance
is pale and sallow.

(iv.) Engorgement of the liver is evidenced by pain and tenderness in
that region, and jaundice of the skin and conjunctivae. The organ is
enlarged, and it may extend even to the umbilicus. Sometimes pulsation
of the liver may be made out by placing one hand on the epigastrium, and
pressing the other beneath the back in the dorsal region. In cases of
dropsy with albuminuria, when we are in doubt whether the dropsy is of
renal or cardiac origin, hepatic enlargement is a valuable diagnostic aid,
for its presence is very usual in cardiac cases, but it is not one of the
consequences of renal disease.

(v.) Indigestion — i,e,, want of appetite, a sense of discomfort in the
stomach after meals, nausea or actual vomiting, with streaks of blood,
indicate congestion of that organ.

(vi.) Albuminuria, with high-coloured scanty urine of high specific
gravity (and possibly casts in long-standing cases), points to congestion
of the kidney.

(vii.) Splenic enlargement and tenderness are the only indications of
congestion of that organ.

la. A Murmur of Dilatation, systolic in rhythm, haviug all the above characters,
and, like it, due to mitral regurgitation, may occur without definite disease of the
valve, when the left vciUridc becomat dilated, and the muscular ring ai\>uud the valve

S 47 ] SYSTOLIC MURMURS 76

faiU to complete the closure of the mitral valve. This oondition is especially apt to
occur io the aged when dilatation of the left ventricle supervenes on hypertrophy. It
alao occurs with chronic renal disease, arterio-sclerosis and ansemia.

II. Aortic Stenocds is another lesion producing a systolic bruit. True
stenosis of the aortic orifice is not common, but a roughness, or the presence
of vegetations on the inner surface of the valves, may produce the same
bruit. The latter is mostly found in old people on account of the degenera-
tive changes, and a systolic murmur thus produced is of relatively less
serious import.

This murmur is characterised by (i.) being loudest at the second right
interspace ; (ii.) it is conducted up to the vessels in the neck, and is audible
in some cases also at the apex (Fig. 16) ; (iii.) it is usually harsh, sometimes
musical, but in many cases it is barely audible ; (iv.) the pulse is small,
sustained, and slow, sometimes anacrotic (§ 59). A systolic thrill is some-
times felt over the base of the heart.

General Symptoms are almost wanting in aortic stenosis — other than
occasional pain, pallor or sallowness of the face, and faintness or giddiness
— until perhaps the mitral valve, owing to backward pressure, gives way
(see Mitral Kegurgitation, p. 73).

The detection of aortic stenosis is sometimes as difficult as mitral stenosis, and
the characteristic murmur may be absent. It may then be suspected when the
patient, generally an elderly man, presents persistent dyspnoea, bradycardia, nervous-
ness, and occasionally anginoid attacks, which are not otherwise accounted for. In
true stenosis the second sound is short and not very loud ; whereas in cases of high
arterial pressure with systolic murmur the second sound is loud. The apez-beat in
stenosis is displaced downwards.

ILL In AoBTio Aneurysm a systolic murmur is the most common one heard
Accentuation of the aortic second sound is the most constant physical sign (§ 53).

IV. Tbictjspid Beotjboitation takes place when that orifice is diseased or dilated.
Some maintain that if the valve be healthy, though dilated, no bruit can be heard,
but it is certain that in cases of confirmed bronchitis a murmur is often present which
comes and goes under treatment, and which is not found to be attended with any
marked changes in the tricuspid valve after death. The murmur is characterised by
(i) being heard best at the tricuspid area — i.e., on the left side of the lower part of the
sternum ; (iL) it may be heard as far out as the right nipple ; (iii.) the pulse is of low
tension, often irregiilar ; (iv.) owing to the accompanying hypertrophy or dilatation
of the right ventricle, the area of dulness extends to the right, and there is epigastric
pulsation ; and (v.) there is also pulsation of the veins of the neck, due to regurgitation
into them, which is distinguished from the undulation seen in simple engorgement by
the fact that the pulsation is not obliterated, but is rendered more distinct when the
finger is placed on the external jugular vein, emptying the vein by the finger, and
noting that it fills from below.

Oeneral Symptoms, as above indicated (p. 74), result from tricuspid regurgitation.
By far the commonest cause is Chronic Bronchitis, which thus presents a clinical
picture (p. 69) readily recognised.

V. PuLMONABY STENOSIS is practically unknown, unless it be part of congenital
malformation of the heart This murmur is systolic in rhythm, loud and harsh, and
is heard over a very wide area, but most distinctly in the second left interspace.

Fallacies in the Diagnosis of Systolic Murmurs. — 1. Ilamie murmurs (§ 402)
are undoubtedly extremely common, and sometimes vciy difficult to distinguish from
thowf of cardiac valvular disease.

7(1 DISEASES OF THE HEART AND FERICARDIUM [ f 47

2. A ayslolic murmur audible in the aortic arta, and having all the chsroctera of It.
above, is due not go often to aortio steuoaia a« to (i.) roughening oE the valve id old
people from atheroma or oaloareoug deposit; (ii.) gimple incompdtnce of the aortic
valvcB may produce both a systolic and a diastolic murmur ; (iii.) atheroma, witli
dihiaiion of the aorta, may also produce a syBtolic or a double bruit : then there is a
ringing second sound in addition.

3. A ajslolio murmur heard best at the second left interspace is Bomctimea present
in iiiitrai rfgargilation with a hypertrophiod left auricle. It must not be mistaken for
pulmonary stenosis.

4. The " milk-ipol " murmur is due to a localised thickening of the visceial peri-
cardium, appearing aa a glistening white spot near the centre of the anterior surtac--
of the heart. Usually it is unattended hy symptoms, but it may bo of importance
clinically, forit iaapt to bo mistaken for valvular disease. The " milk-spot" murmur
(based on twenty-tbrec observations, verified by autopsy, at the Paddingtoa Infirmary)
is generally » prolonged rough bruit, systolic in time, though occisieiially double ; it
in ttriiMy localised to a circle of 1 or 1 J inches radius, whoso cent™ is situated in the

Fig. H —The lyitoUc raurmur ol aortic Fig. IB.— Tlis disitoUc mnimur el »ortlC

(tenoil* liBpth el ihadiog indi- reRurgltatlon. Depth ol shading

rates intensity ol murmur, indicates Inlenalty el muriDtu'.

third left intersliaoe, cIo.ho to the sternum, which is also its position of maximum iu-
tensity, Anither important feature is that at one lime it m very rough and loud, and
a day or so later it may have completely disappeared. These features, and the
absence of the concomitant symptoms of cardiac s'.'.Kular disease, or of chlorosis.
enable us to differentiate the milk-spot murmur from other conditioua. It was foimil
more often in hyportrophied hearts than in those of normal size. It has been variously
attributed to tight -lacing, the soldier's shoulder straps, and other lesa probable causes.
The condition is more frequently met with in adult or advanced life. A history of
perioarditia waa obtainable in only one of the twenty -three cases,

5. A cottgeniUd murmur, usually systolic and localised t« the base, has been known
— in rare cases — to porsiat throughout life in some persona who have never experienced
any other manifestation of cardiac disease, although they have lived to a good old age.

0. A systolic murmur heard shortly after the first sound may bo heard at the apex
at one stage of mitral stenosis (itiackenzie}.

7. Cardio-pulmonary or Cardio-respiratory murmurs are also rare, and aro probably
produced by the expulsion of air from the adjacent lung tissue by tlio raovementa of
the hoart. They do not indicate any canliao lesion, and the lung may also lie healthy ;

§47] DIASTOLIC MURMURS 77

but they are sometimes associated with phthisis when the cavity in near the heart.
They are heard in various parts of the antero-lateral region of the chest. Thoy have
a blowing, whiffing, or " sipping " character, are usually systolic in rhythm, and in
rare cases double, though the systolic element is always loudest. Often they are not
loudest at the apex, and come rather between the two sounds than with the first
sound. Sometimes they disappear when the patient alters his position or stands up.
When he stops breathing, they may be weakened, abolished, or unaltered.

B. Mnrmnn heard in the diasMic interval may occupy either (a) the
first half of that interval, replacing, accompanying, or following the
second heart sound (Dictstolic murmurs) ; or (b) they may occupy the
second half of the interval, preceding and leading up to the first heart
sound (Presystolic murmurs) (see Fig. 20).

Murmurs of the first kind are produced, in order of frequency, by aortic
regurgitation, aneurysm, and pulmonary regurgitation ; murmurs of the
second kind are mostly due to mitral stenosis, very rarely to tricuspid
stenosis.

I. In Aortic Begorgitatioii the murmur is diastolic (Ventricular Dias-
tolic), ^ and is (i.) audible in the aortic area (second right space), but it is
often loudest at the third left intercostal space ; (ii.) it is conducted down
the sternum, and audible at the apex (Fig. 19). It is, therefore, one of the
loudest and most widespread of murmurs, (iii.) Owing to the amount of
dilatation and hypertrophy of the left ventricle, the apex is displaced
downwards and outwards more than in any other form of valvular disease,
(iv.) The pulse is the characteristic " water-hammer " (§ 62). The face
is pale, and the carotids visibly pulsate. Capillary pulsation is generally
present, and is detected by drawing a line across the forehead, or by
lightly pressing on the finger-nail or on the lips with a glass slide ; the
alternate blush and pallor due to the pulsation in the capillaries is thus
well brought out. So great may this be that a pulse is sometimes com-
municated to the veins on the dorsum of the hand.

General Symptoms in aortic regurgitation : (i.) Pain about the chest,
often of an anginoid character, may be complained of before compensation
fails, or true angina may be present, (ii.) The anaemia is greater in this
than in aortic stenosis. Faintness, giddiness, frontal headache, and dis-
turbed sleep are common, (iii.) Dropsy is rare, as death usually occurs
before the mitral valve yields sufficiently to produce the necessary back-
ward pressure. Embolism sometimes occurs, though not so often as in
mitral stenosis.

II. In BGtral Stenosis the murmur is presystolic in time. It occurs
during the contraction of the auricle, and is known, therefore, as the
auricular systolic or A. S. murmur. It is heard (i.) at the apex, and
(ii.) over a very limited area, (iii.) The murmur is rough or rumbling,
and crescendo in character, running up to a loudly accentuated first sound,
(iv.) A reduplicated second sound is heard best just to the right of the

^ Diastolic murmurs are sometimes spoken of as V.D. murmurs, being produced
during the ventricular diastole. Similarly, presystolic murmurs are spoken of as A.S.
murmurs, being produced during the auricular systole.

78 DISEASES OF THE HEART AND PERICARDIUM [ § 47

apex.i (v.) On palpation, a characteristic sigji in this heart lesion is the
presystolic thriU, It may be/efe even before the murmur can be heard —
i.6., before the number of vibrations per second are sufficient to produce
a musical note. In the later stages it disappears altogether, (vi.) The
apex-beat is not displaced to the left ufdess regurgitation he also 'present ;
but the prsBCordial area of dulness is increased to the right, owing to the
hypertrophy and dilatation of the right ventricle, (vii.) The pulse is
small and of fair tension, until compensation fails.

In the later stages of mitral stenosis the presystolic murmur disappears,
and sometimes a mid-diastalic or an early diastolic murmur is heard
(Fig. 20). This diastolic murmur has a diminuendo character, and is
only audible near the apex. Sometimes the second sound is absent at
the apex.

Later still, there may be no murmur at all, and then the characteristic
** slapping " (short, sharp) first sound and irregular rhythm of the heart

form the sole auscultatory signs. This
^"^ I" e^ i« s«* I** form of cardiac valvular disease is
diastole| [DtASTOLgl [diastole I commoner m women, and, m my
— '*"iwi I Ki^ I illliih^ I experience, in children.

^ ^ ^ General Symptoms. — (i.) Pulmonary

Fig. 20.— Three murmun may be met with congestion (p. 7^, ante) IS especially

ill Mitral Stenosis, which may oc- «^,«*^,^« . «^«„««„««4.i„ k «>.>-» ^^*^ro;« :«
cupy different parU of the diaatoiic in- common ; consequently haemoptysis is

f*r?''»i^^*?;j; ther^rore be called the more frequent in this than in other
(a) LATi, (6) MID, and (c) early dia- . i. , t ... v i i-

sTOLio MURMiTRs. The late diaatoiic forms of valve disease ; (u.) emboli are

• — i.e.y preBystolic — murmur is the i t ^ /••• \ j

commonest : the early dJastoiic ig least ^Iso more frequent; (ill.) dropsy IS
frequent. The redupUcation of the rare until the end, but, on the failure

second sound has been omitted for the . . i n i

sake of clearness. of the right ventricle, all the symp-

toms of right ventricular dilatation
appear. Liver enlargement is more common, but cyanosis and dropsy
are less common in mitral stenosis than in regurgitation.

III. In Aortic Aneurysm a diastolic murmur is sometimes heard, but the murmur
is usually systolic in time.

IV. Tricuspid Stenosis is a raro condition, but it is occasionally met with in
young women, and is recognised by (i.) a presystolio murmur, heard loudest over the
fifth right costal cartilage, close to the sternum, (ii.) Dropsy precedes the pulmonary
engorgement, but in other respects the consequences are the same as those of regurgi-
tation through this orifice.

V. Reouroitation through the pulmonary artery is practically never met with,
excepting either as an accompaniment of congenital malformation of the heart, or as
part of a general valvular inflammation in acute ulcerative endocarditis.

Fallacies in the Diagnosis of Diastolic Murmurs. — 1. A diastolic murmur due
to aortic regurgitation may be heard at the apex. It must not be mistaken for mitral
stenosis. In addition to the fact that the aortio murmur is heard louder at the base

^ This so-called * reduplicated second " is supposed to be due to a short diastolic
murmur following the second sound, because it is heard at the apex, where the pul-
monary second is said not to be audible ; and because, if due to asynohronous closure
of the aortic and pulmonary valves, from the high pressure in the pulmonary circula-
tion, one would expect it to be heard in mitral regurgitation, and in the later stages of
mitral stenosis, in both of which it^ absent.

§ 48 1 DIASTOLIC M URM UBS 79

than at tho apex, it has a uniform character, whereas a mitral diastolic murmur is
broken, of varying intensity, and the pulse and other symptoms are different.

2. A prtsyiclic apical murmur is occasionally heard with aortic regurgitation
(Austin Flint murmur). It is diagnosed from that due to mitral stenosis by its not
being followed by an accentuated first sound, by the position of the cardiac impulse,
and by the absence of the other signs of mitral stenosis.

3. Mitral stenosis is the most difficult form of valvular disease to detect in the
second or third stages, when the characteristic murmur may be altogether absent. It
may, then, be strongly suspected when there is — (i.) a loud, clear, sharp first sound
at the apex, with marked accentuation of the pulmonic second sound ; or (ii.) hyper-
trophy of the right ventricle, chronic pulmonary catarrh, and hi^moptysis, especially
if the second sound is reduplicated or absent at the apex.

C. Double Mnrmnrs may be produced by a combination of any of the
above systolic and diastolic murmurs.

(a) Double murmurs most audible at the base (other than hsBmic) :

1. Combined Aortic Obstruction and Regurgitation is the most
common condition, and causes a loud double see-saw murmur, heard best
in the second right interspace.

II. Aneurysm of the Aorta may be attended by a double murmur
having the same characters as in disease of the aortic valves. This is
heard loudest in the second right interspace, but it may also be heard at
the back, to the left of the fourth dorsal vertebra.

III. A double murmur occasionally occurs in the dilated aorta of the
age<l, but with less marked features.

IV. A double murmur, loudest in the pulmonary area, nsually indicates Congrnitat.
Hkart Disease.

(6) A double murmur most audible at the apex may be heard when both

Mitral Regurgitation and Stenosis are present. It consists of a

systolic bruit followed by a long diastolic murmur almost filling up the

diastole.

Fallacies in the Diagnosis of Double Murmurs. — 1. When a double murmur
can be heard both at the base and apex, do not imagine that mitral regurgitation
exists, as well as aortic disease. Remember that a systolic mitral and a systolic
aortic may be alike in character, and that aortic murmurs can often be heard at the
apex, as well as the base. To arrive at a conclusion is often very difficult, but one
must rely on the position in which the murmur is loudest, and on the other features
which distinguish mitral and aortic lesions.

2. When a double aortic murmur is present, the lesion may be regurgitation, or
stenosis, or both together. A diagnosis is made by examining the pulse (§ 62), tho
rhythm of the thrill, if one is present, and the position of the apex- beat. In regurgi-
tation the apex is displaced farther downwards and outwards than in any other form
of valve disease. In aortic stenosis the left ventricular wall is hypertrophied, with
but little enlargement of the cavity, and as emphysema is so often associated with it,
the apex may bo hard to find.

3. Murmurs of pericardial friction may easily be mistaken for a double aortic
murmur.

4. Hcsmic, cardio-pulmonary, and milk-spot murmurs are occasionally double.

§ 48. General Symptoms of Cardiac Valvular Disease. — The first
effect of valvular disease is hypertrophy of the heart, as already mentioned,
and so long as there is adequate compensatory hypertrophy there may be
no concomitant symptoms at all.

80 DISEASES OF THE HEAUT AND PERICARDIUM [§49

But, sooner or later, in most cases hypertrophy f»ives way to dikUation,
and then a series of characteristic symptoms ensue. Those special to each
form of valvular lesion have been referred to in the preceding section.
Certain general symptoms are common to all formes of chronic valvular
disease,

1. Breaihlessness on walking uphill, or even on very slight exertion, is
a very constant feature. No serious enfeeblement of the heart wall or
disturbance of its function can exist without this symptom ; and it cannot
be too much insisted on that breathlessness is not only a symptom, but,
in general terms, is a measure of the extent of the cardiac failure.

2. Dropsy occurs early in mitral, late in aortic, disease.

3. Palpitation is of less diagnostic import, for it may occur without any
organic heart change, and is not always present with valvular disease.

4. Pain is by no means always present in cardiac dilatation, but few
cases run their entire course without considerable prsecordial discomfort.
Pain is a fairly common feature of aortic disease, and sometimes amoimts
to angina.

5. Insomnia, in advanced cases, is frequently a very troublesome
symptom. Sometimes the patient, when dropping off to sleep, suddenly
starts with the terror of suffocation, and gasps for breath. Headache and
delirium are also met with in advanced cardiac disease. The former is
occasionally due to temporary high tension, but both are more often due
either to pyrexia or to a toxic condition of the blood from failure of the
emunctories. In either case free purgation is indicated.

6. Embolism may occur, having all the features described under Acute
Endocarditis (§ 39). It is most frequent in mitral stenosis, and next in
aortic disease.

§ 49* The chief Cause of cardiac valvular disease in youth is acute endo-
carditis, which has a special tendency to attack the mitrcU valve, and in
advancing years the chronic degenerative changes, which attack the aortic
orifice.

1. Acute Endocarditis of rheumatic origin is by far the most frequent
cause, and a large majority of " heart cases " date their symptoms from
an attack of that disease in youth or early adult life. Scarlatina and the
other acute specific fevers, and all causes of acute endocarditis (§ 39), play
their part, but the other specific fevers are infrequent relatively to acute
rheumatism and scarlatina.

2. Chronic Endocarditis may come on insidiously, especially under the

influence of certain poisons, chief among which are alcohol, sj'philis, and

gout, and especially if these be combined with hard labour. Under such

circumstances, the lesion usually affects the aortic orifice. But chronic

endocarditis more often supervenes upon acute endocarditis — an attack

of which may have been overlooked.

Dr. C. O. Hawthorne has done good service in drawing attention to the fact that
endocarditis may start with an apparently trivial attack of Rubactite rheumatism, the
child complaining of nothing but slight pains in the limbs, accompanied pethaps with

S 50 ] PROQNOaiS OF CARDIAC VALVULAR DISEASE 81

a slight sore throat, not of sufficient gravity for him to be kept in bed. Parents of
children whose antecedents are rheumatic should be warned not to treat such symptoms
lightly.

3. Degeneraiive changes {e.g., atheroma) are the lesions chiefly met with after middle
life. They af^t essentially the aortic orifice, either by injuring the valves or by
causing dilatation of the aorta, which, extending to the situation of the valves, prevents
them from meeting during the diastole.

4. Any prolonged high tension — cgr., that which accompanies arterial sclerosis — may
lead to valvular strain, usually aortic. Persistent obstruction in the lungs (e.^.,
chronic bronchitis), or in the general systemic circulation, may have the same effect
as persistent high tension on the right or left side of the heart respectively.

5. Extensive or prolonged miiscular exertion may, it is believed, lead to valvular
mischief — at least, there is no other mode of explaining the fact that a large number
of athletes have sclerosis of the aortic valves. In rare circumstances a sudden strain
may lead to rupture of a valve.

6. Congenital conditions are referred to in § 46.

§ 50. Tlie Prognosis of chronic heart disease is but ill-understood if the
conclusions are based only on hospital cases. They need to be followed
from beginning to end as in private practice or infirmary work. It is quite
certain that many patients have disease of the heart for years without
knowing it. It is also certain that the first symptoms very often date
from the patient knowing that he has cardiac disease, and unless there are
special reasons- to the contrary, a patient should never be informed of its
presence.

Cardiac disease may terminate life in three ways : (i.) By sudden death
— this may result either from syncope, or from rupture of the heart, or,
as some say, from cardiac anaemia, due to non-filling of the coronary
arteries; (ii.) by the occurrence of complications, especially bronchitis,
and other pulmonary affections ; or (iii.) by asphyxia, from dropsy of the
pleura, often combined with congestion of the lungs.

The probable course and duration depend upon many considerations,
but on nothing more than the condition of the cardiac waU (No. 3 below),
and this should be the object of the most thorough investigation.

1. The presence of certain Cardiac Symptoms is in itself an indication
that the reserve power of the cardiac muscle is overdrawn — e.^., palpita-
tion, dyspnoea, increased by emotion or exertion, cardiac pain, syncopal
and anginoid attacks. In actual practice the prognosis is good in pro-
portion to the amourU of exercise a patient carh take toithout froiucing
breatMessness.^ Syncope and anginoid attacks usually indicate serious
cardiac embarrassment. Palpitation and cardiac pain are less serious
indications; "Delirium cordis" and Cheyne-Stokes breathing are very
grave (§§ 206 and 44).

2. The Condition of the Pulse is of considerable value in prognosis, but
it has to be judged in connection with the valvular lesion. Irregularity
is a grave indication except in mitral regurgitation ; in aortic disease it is
very serious. Persistent irregularity with rapidity is always a bad sign,
and may indicate the onset of auricular fibrillation (see below).

^ Mackenzie states : ** The simple test is to observe how the heart responds to
effort. . . . Heart failure is first exhibited by a diminution of the work force of the
heart, and this is shown by a restriction of the field of effort."

82 DISEASES OF THE HEART AND PERICARDIUM [§60

3. The Physical Signs of Cardiac Hypertrophy and Dilatation given in
Table III., p. 68, will help us to gauge the amount of dilatation — i.e.,
failure, or hypertrophy — i.e., compensation which is present, by means of
a careful examination of the apex- beat, by percussion, and auscultation.
If emphysema or other condition prevents us obtaining reliable conclusions,
it is worth remembering that a regularly acting heart with an apex in the
normal situationy justifies (with possible exceptions in mitral stenosis) a
fairly good prognosis.

For purposes of prognosis — and, indeed, for treatment also — cases of
cardiac valvular disease are best divided as follows : In the first stage
there is efficient hypertrophy, with or without compensatory dilatation (in
regurgitant lesions dilatation is also a compensatory process and aids the
heart). In this stage the patient may not come under notice at all ;
both the valvular mischief and the hypertrophy may be discovered
accidentally.

In the second stage the dilatation increases, and some of the symptoms
referable to the heart, above mentioned, are sure to be present. The
dilatation, however, is not sufficient to produce pulmonary or systemic
engorgement. The characters of the murmurs vary as years pass, owing
to changes in the cardiac muscle, and hence in its contractile force.

In the third stage there is advanced dilatation, with thinning of the wall
and congestion of the lungs (in aortic lesions), of the general venous
system (in mitral lesions), and finally of both.

" Auricular fibrillation " may supervene, and is a sign of the gravest
import. Fibrillation is a condition in which the various muscular fibres
of the heart contract rapidly and independently of each other. Owing
to the resulting conflict of action of the different fibres the normal con-
tractile wave from auricle to ventricle via the auriculo-ventricular bimdle
of His is suspended, and the chambers of the heart tend to dilate. When
fibrillation occurs in the ventricle it leads to death ; when it occurs in the
auricle, the normal stimulus of the contraction wave is replaced by rapid
and irregular stimuli, which in turn affect the ventricular rhythm. In
most cases of cardiac failure the onset of auricular fibrillation is evidenced
clinically by a pulse of rapid and disorderly rhythm — i.e., no two successive
pulse beats or intervals are alike. In cases of heart-block the pulse is
slowed. In mitral stenosis the onset of auricular fibrillation is evidenced
by the disappearance of the presystolic murmur. Other clinical signs of
auricular fibrillation are an absence of the auricular wave in tracings of the
jugular vein and of signs of an auricular systole in an electro-cardiogram.
The patient is usually conscious of a fluttering or thumping sensation
about the heart and an aggravation of his other symptoms of cardiac
failure. Fibrillation is met with chiefly in two classes of cases — (1) those
with a history of rheumatic fever, and (2) elderly patients with fibroid
degeneration of the heart. Dr. Mackenzie finds that 70 per cent, of cases
of cardiac failure in general practice are due to the onset of auricular
fibrillation.

§50] PROONOSIS OF CARDIAC VALVULAR DISEASE 83

f 4. The presence of signs of venous obstruction as a measure of backward
pressure — viz., pulmonary congestion, dropsy, lividity of the lips and
fingers, enlargement of the liver and spleen, and albuminuria — is un-
favourable. But the gravity is very different in mitral and aortic lesions
respectively.' In mitral cases a moderate degree of these symptoms
indicates only moderate cardiac failure, and it by no means follows that
the heart is beyond redemption. But if they occur in aortic disease they
show that the final stage is reached, and that the patient will probably not
live many months. When general venous congestion exists, the relative
amount of urine passed day by day is a good measure of the strength of the
heart and the improvement made — a fact which is not generally appreciated.

5. Concerning the Nature of the Valvular Lesion as bearing on the
pn^osis, some difference of opinion is expressed as to the relative im-
portance of aortic and mitral lesions. My own experience is that a
moderate degree of aortic stenosis is the most favourable form, and if well
compensated may give rise to little or no inconvenience ; the patient
generally dying of some intercurrent malady. Next in order comes mitral
regurgitation, then mitral stenosis ; the most serious being aortic re-
gurgitation, the valvular disease which most frequently ends in sudden
death. Combined lesions of stenosis and regurgitation are naturally more
serious than single ones, and the gravest of all valvular lesions is double
aortic disease.

In Aortic Regurgitation, the measure of the amount of regurgitation, and
therefore the prognosis, depends upon the clearness with which one can
hear the aortic second sound (as distinct from the murmur) in the carotid
arteries, and on the degree to which the pulse collapses. In Mitral Re-
gurgitation a loud muxmnT/oUomng the first sound is more favourable than
a weak murmur, or than one which replaces or accompanies the first sound.
In Mitral Stenosis a faint or absent second sound is a grave sign. Apical
murmurs due to dilatation can generally be made to disappear undei*
treatment.

In Double Aortic Disease it is important to note which is the louder, the first or thu
second of the two bruits. If the first be the louder, it indicates considerable compen-
sating hypertrophy of the left ventricle, and the prognosis is more favourable ; but
if the second (the regurgitant) bruit be the louder, it probably indicates a weakened
ventricle, which allows a large reflux of blood, and the prognosis is as grave as well
can be.

6. The Primary Cause of the valvular mischief influences the prognosis to some
extent. Injury and congenital mischief, both happily rare, are very serious. Kheu-
matism is grave in proportion to its tendency to recur. In general terms cases due
to acute endocarditis in early life are much more favourable than the degenerative
changes (accompanied perhaps by an alcoholic or syphilitic taint) supervening during
middle liiPo.

7. Age is not a very important factor. Valvular lesions in childhood are more
Toad'ly compensated, but at the same time advance more rapidly. Mitral stenosis
coming on in childhood is much graver than when it supervenes in the adult, and
generally terminates fatally before the age of twenty-one. On the other hand, aortic
regurgilation due to endocarditis in youth is compatible with a long and useful life ;
but when coming on in middle or advanced life, it is generally due to degeneration and
dilatation of the aortic orifice — a condition of far graver import.

84 DISEASES OF THE HEART AND PERICARDIUM [ f 51

8. The Temperament, Habits^ and Means of the patient will naturally influence his
future. Want of rest and sleep, the presence of worry and other causes of nerve
strain, seriously affect the prognosis in all forms of cardiac disease. The prognosis ia
bad in the intemperate, and those who lead irregular lives. It is also unfavourable
in the destitute, and in those who are compelled to work hard for their daily bread.
Nevertheless, complete idleness is equally bad, and a patient should b^ encouraged to
do as much as he is able without fatigue.

9. Finally, before hazarding a prognosis in any given case, the Effects of TreeUment
should always be watched, for it is sometimes truly wonderful how the skilful adminis-
tration of digitalis, and the application of modem methods of treatment, will some-
times seem to snatch the patient from the very jaws of death. The existence of an
organic murmur without change, and not requiring active treatment for two years,
justifies a favourable prognosis.

§ 51. The Treatment of Chronic Heart Disease (including Cardiac
Dilatation or Failure and Valvidar Disease) may be considered under three
heads : (a) When compensation is fully established ; (b) when compensation
begins to fail ; (c) when compensation has broken down.

(a) When there is eflficient compensation, no symptoms are present and
no active treatment is needed, but much may be done to prolong the
patient's life, and to avoid the supervention of cardiac failure. Subjects
of chronic valvular disease should be enjoined to lead quiet, regular, and
orderly lives. They should be warned particularly against the dangers
of any sudden, imusual exertion, such as running to catch a train. With
regard to exercise, it may be said, in general terms, that the patient himself
is the best judge, provided always that he does not exert himself sufficiently
to cause palpitation, severe dyspnoea, or prsecordial pain. Some sports
are more peimissible than others ; thus cricket, tennis, and golf may
usually be enjoyed, whilst football, racing, and rowing must generally be
forbidden. Climbing, especially to high altitudes, must be disallowed.
Alcohol, tobacco, and tea are all myocardial poisons if taken to excess,
and should be used only in strict moderation. The skin should be kept
active by the daily bath, and the bowels regular by means of purgatives
if necessary. Whenever possible, a means of livelihood should be chosen
in which the heart is subjected to but little strain. A sedentary occupation
with moderate exercise in the intervals, is more suitable than that which
entails earning a living literally by the sweat of the brow. Lifting or
carrying heavy weights, climbing ladders, wielding heavy hammers, and
physical labour in constrained positions, are liable to overtax the powers
for compensation of the cardiac muscle. Meals should be regular, and
heavy meals should be avoided. The diet should be easily assimilable,
and contain only a moderate amount of fluid. Anything requiring pro-
longed digestion disturbs the night's rest, so that it is sometimes a good
rule to allow nothing solid after 2 p.m. in those who have a tendency to
indigestion or gastric disturbances. A small quantity of stimulant with
meals may be called for, but should not be used unnecessarily, because of
the reaction afterwards, and of the tendency to excess, which exists in
cardiac cases.

{b) When compensation is beginning -to fail, the condition of the heart

Itt] TREATMENT OF CARDIAC VALVULAR DISEASE 85

should be noted frequently ; rest, drugs, and exercises being prescribed in
accordance with the variations in the circulation and the capability of
response to treatment by the cardiac muscle.

Drugs. — In cardiac failure, especially when the pulse becomes feeble,
rapid, and irregular, digitalis is par excellence the remedy. It is especially
indicated in failure of the right heart and in mitral regurgitation, whetlier
primary or secondary to aortic lesions. It is contra-indicated when there
is full compensatory hypertrophy, and the pulse is fairly strong, regular,
and slow, or if vomiting is present. The recent work of Dr. James Mac-
kenzie has thrown much light upon the action and modes of administration
of digitalis. It slows the heart, and improves contractility and con-
ductivity; in overdoses it induces heart-block. It should be given in
large doses (,"^i. daily) to get the muscle thoroughly under its influence ;
the dose is then reduced to the minimum which experience and careful
observation proves to be capable of maintaining the regularity and slow-
ness of the pulse. It is especially useful in auricular fibrillation, except
where there is pyrexia or fibroid degeneration, when the muscle does not
respond to the drug. It should be continued for a considerable time in
smaller doses in the form of a tonic. Strophanthus and other cardiac drugs
are less efficacious than digitalis. The action of digitalis and many other
cardiac remedies is expedited by an occasional dose of calomel. Formulae
54, 57, 59, 67, and 84 are useful. In aortic valvular disease and in the
early stages of mitral stenosis, digitalis is not so valuable a drug; but in
the later stages of these affections, when compensation begins to fail and
signs of auricular fibrillation are present, digitalis gives relief. In aortic
cases, where the blood-pressure is high, or where angina is ^resent, the
vaso-dilators are often of most use, such as nitroglycerine (in the form of
liquor trinitrini \[\i. t.i.d.), or er3rthroltetra-nitrite, sodium nitrite, and sal
volatile. Belladonna is sometimes useful if there is relaxation of the
vessels. Among the cardiac tonics strychnine, nux vomica, iron, and
arsenic are the most valuable in the order mentioned.^

The various symptoms may be met by appropriate remedies. For the
jndmonary congestion, squills and stimulating expectorants are indicated.
For breathlessness, spirits of ether or of chloroform and ammonia are
useful. Nitroglycerine is useful where breathlessness is associated with
high tension, which may accompany cardiac hypertrophy ; and at the
same time it cures the headache and sleeplessness due to the same cause.
Ether m^xx. to xl., or strych. sulph. gr, ^V hypodermically, are useful for
the paroxysms of dyspnoea. Cough is relieved by drinks of hot milk, and
drugs such as codeia, small doses of opiimi, and chloroform or ether. For
jHdjniation alcohol is a most valuable cardiac stimulant, and relieves the
breathlessness as well. Unfortunately, patients soon find this out for
themselves, and thus cardiac valvular disease is a not infrequent cause of

^ Cane-sugar in the form of glebe granulated sugar in doses of 1 to 5 ounces twice
or three times daily is strongly recommended in failing myocardium, from whatever
cause, by Dr. Goulston, {Brit. Med. Journ,, March 18, 1911) and Dr. Carter Brit. Med.
Jaum., November 26, 1911).

86 DISEASES OF THE HEART AND PERICARDIUM [ § 61

chronic alcoholism, especially among women, who take it secretly, during
the night, when the palpitation is most apt to come on. The exact dose
should therefore be carefully prescribed, and the quantity should always
be moderate. Other causes of palpitation which may be present should
be treated (§ 22). For sleeplessness opium or morphia hypodermically is
useful ; in mitral disease, however, where the liver is congested, opium is
better avoided, and other drugs employed, such as potassium bromide,
sulphonal, trional, and paraldehyde. I have not found small doses of
chloral do harm, as some maintain. The hcBmoptysis of heart disease is
best left alone, as it relieves the congestion. The gastric symptoms
may be relieved by acting on the congested liver with calomel, i to 1 grain
every night, with sodium sulphate and sodium bicarbonate (30 grains in
2 ounces of hot water) in the mornings. Digitalis must be stopped if it
causes sickness. It may be necessary to give predigested food. For the
treatment of syncopal attacks and pain, vide §§ 24 and 23. Formula 56 is
useful.

Massage and Systematised Exercises, — At one time rest was regarded as
imperative for all forms of cardiac disease. But the advance of physio-
logical knowledge has shown what an important part the skeletal muscles
play in the circulation of the blood, by squeezing the fluids out of the soft-
walled veins and lymphatics, while they cannot compress the lumen of the
firm-walled arteries. There are three varieties of this treatment, which
are invaluable for different degrees of cardiac failure. Fir sty for the worst
cases, gerUle nwssagey combined perhaps with passive movements. These
are available where any kind of voluntary movement on the part of the
patient is attended with breathlessness. The great value of properly
regulated massage in cardiac failure is well seen in the case from which the
tracings in Fig. 22 were taken. Secondly^ slow volurUary movements of
flexion and extension on the part of the patient while standing or sitting.
In the Nauheim system these vohmtary movements are gently resisted
by the operator — "resistance gymnastics" — see Formula 114. These
movements, combined with baths (see below), constitute the essence of the
Schott system. Thirdly, OertePs method, which consists of three parts :
First, reducing the amoimt of fluid taken to 31 ounces per diem (to include
the amount contained in the solid food) and promoting perspiration ;
secondly, a diet largely consisting of proteids ^ ; and thirdly, graduated
exercise in the form of walking uphill, each day a little farther. Cases
attended by plethora and obesity are the most suitable.

Baths, such as those in use at Nauheim, may be usefully added to the
preceding. They act by relaxing the arterioles of the skin directly, and

* Oertel's dietary is as follows : — Morning : 6 ounces of coffee, 3 ounces of bread.
Noon ; 3 to 4 ounces of soup, 7 to 8 ounces of roast meat or poultry, salad or green
vegetable, a little fish, 1 ounce of bread or farinaceous pudding, 3 to 6 ounces of
fruit ; no liquid (excepting in hot weather, 6 ounces of light wine). Afternoon :
6 ounces of tea or coffee (1 ounce of bread occasionally). Evening : one or two lightly
lH)iled eggs, 1 ounce of bread, salad, fruit, sometimes a small piece of choose,
G to 8 ounces of light wine, with 4 to 5 ounces of water.

SU]

TREATMENT OF CARDIAC VALVULAR DISEASE

the arterioles of other parts reflexly. By these means blood is transferred
from the venous to the arterial system, and its flow accelerated (F. 113),

(c) When compensation has broken down and marked cardiac failure
is present, absolute rest is necessary. The patient is usually imable to lie
down, but has to be propped up with pillows, and in severe cases sleep can
be obtained only when the legs are hanging down. In severe failure of the

V.'

Fig. 21.— TracingB A and B show the efficiency of bleeding. A shows the flat top of high tension.
B was taken Immediately after 6 ounces of blood were removed, and shows Uie reduction
thus effected, and also the senile character of virtual tension. The patient was about fifty-
seven years of age, and suffered from cardiac valvuUr disease with recurrent high tension
(with headache, ete.). The urine was always normal. Some years later he was brought in
with apoplexy and died.

right heart, as indicated by orthopnoea, lividity, distended jugular veins,
the liver dulness extending well below the costal margin and the cardiac
dulness extending far to the right, venesection is called for, and brings
prompt relief. The abstraction of from 5 to 10 ounces of blood is usually
sufficient ; its efficacy is shown in Fig. 21, above. Three to six leeches may
be applied to the right lower ribs in children, in whom venesection is more
difficult to perform. The dropsy may require special treatment, such as

Fig. 22. Pulse tracings C and D are taken by a Marey's sphygmograph (in which the momentum
of the lever is greater and the excursion larger, than those taken by Dudgeon's). C (which
shows simply high tension) was taken before, and D (which shows the reduction of tension)
was taken directly after maitiitge — massage and passive movements. The patient was a
man aged sixty-five, under carefor arterial sclerosis, and these tracings show the efficacy of
massage in relieving the heart.

draining the legs by Southey's tubes (§ 21) or multiple superficial incisions.
Aspiration of a pleural effusion or paracentesis abdominis may be neces-
sary. Diaphoretics are of little use in cardiac dropsy. Cardiac tonics,
such as digitalis and caffein, should be employed in conjunction with
diuretics, calomel, and hydragogue cathartics, such as pulv. jalapae co.
and cream of tartar. The digitalis, squill, and calomel pill is useful at
this stage ; so also Formula 55. Diuretin and theocin-sodixmi acetate arc

88 DISEASES OF THE HEART A^D PERICARDIUM [ § 52

valuable drugs when dropsy is excessive. A salt-free diet should be
ordered. The readily difiusible stimulants such as spirits of nitrous ether,
alcohol and sal volatile are of great value.

VI. On auscultation, no murmur can he heard, and the heart sounds are
very feehle ; the impulse is so weak thai it cannot be localised. Fatty
or Fibroid Degeneration of the heart toaU may be strongly suspected.

§ 52* Fatty Heart in its clinical sense indicates enfeeblement of the
cardiac wall. A better term for it would be Cardiac Enfeeblement, or
Primary Cardiac Failure. Examples have now been given of all the various
physical signs liable to be found in the heart by means of inspection,
palpation, percussion, and auscultation. But, supposing the most careful
examination reveals no physical signs, although, by reason of certain
subjective symptoms, we believe the patient to be sufEering from cardiac
disease. Fatty or Fibroid Degeneration op the Cardiac Wall should
be suspected. The diagnosis often rests on a process of exclusion, and the
two forms are clinically indistinguishable from one another.

Its detection is often a matter of some difficulty, but the disease may
be suspected (i.) when the pulse and heart impulse are feeble, and the heart
soimds perhaps inaudible ; (ii.) if the patient be subject to attacks of
fainting or of dizziness; and (iii.) if he be subject to palpitation and
breathlessness. The patient may experience no symptoms at first beyond
a tight feeling across the chest on exertion ; later, he may have dyspnoea,
especially at night or after movement. The pulse may be either very
quick or very slow, intermittent, or irregular, due to extra-systoles. The
disease is more frequently met with in persons past middle age, and if
unaccountable fainting attacks occur for the first time at this age period,
fatty heart is the most probable cause. Some oedema of the ankles may
also be present, (iv.) The heart sounds are not usually accompanied by a
murmur, for even if valvular mischief exist, the force of the heart may not
be sufficient to produce a bruit.* With the onset of cardiac dilatation the
area of prsBcordial dulness may be increased, but it is often obscured by
emphysema of the lungs, which is itself one of the causes of fatty degenera-
tion. Later on, anginoid and epileptiform attacks, or the syndrome known
as Stokes- Adams disease (§ 59) are not uncommon.

The Prognosis is extremely grave. Fatty heart is one of the commonest
causes of sudden death. The earlier stages of the malady are insidious, so
that by the time pronounced symptoms appear irreparable mischief may
be done. The patient may die in one of the syncopal attacks, or, if not,
he will rarely live for more than six to twelve months after definite symp-
toms have set in, such as dyspnoea, Cheyne - Stokes respiration, or a
continually irregular pulse, especially the pidsus alternans. In the early
stages of cardiac degeneration plenty of fresh air exercise and good sleep
are essential for increasing the reserve power of the unaffected muscle
fibres, and if the patient responds to this treatment he may live for many
years (Mackenzie).

§58] FATTY HEART 89

Diagnosis, — In the early stages it may be impossible to distinguish
Fatty Heart from Cardiac Dilatation, especially when emphysema is
present, preventing accurate percussion. In dilatation there is nearly
always anasarca, fluid in the serous cavities, and congestion of organs.

Treatment consists of (i.) perfect rest, both of body and mind, and
avoidance of anything like excitement ; (ii.) stimulants in small and fre-
quent doses — ammonia, alcohol, ether, combined with plenty of easily
assimilated nourishment, and potassium iodide where the arterial system
is affected, (iii.) Cardiac tonics, and especially strychnine, arsenic, and
quinine, combined with plenty of fresh air. Digitalis should not be given
if there be no signs of dilatation and the pulse be slow. It is, however,
of great value in the opposite conditions, (iv.) The heart may be relieved
of some of its work by passive movements, massage, and other measures
described under Cardiac Valvular Disease, due care being exercised;

CHAPTER IV

ANEURYSM OF THE AORTA AND OTHER INTRATHORACIC

TUMOURS

Anatomy. — The mediastqiain is the irregular space in the chest which lies between
the two pleural sacs. For descriptive purposes it is divided into four parts — viz., the
middle mediastinum, which is occupied by the heart and pericardial sac ; the anterior,
which is the space in front ; the posterior, the space behind ; and the superior, the
space above the pericardial sac. The most important structures contained in those
spaces are : The thymus or its remains ; the arch of the aorta with its branches
(innominate, left subclavian, and carotids) ; the superior and inferior venae cavte,
with the innominate and azygos veins ; the pulmonary vessels, the trachea and bronchi ;
the vagus, recurrent laryngeal, phrenic, and splanchnic nerves ; the cardiac and pul-
monary plexuses ; the roots of the lungs ; the oesophagus, thoracic duct, lymphatic
glands and vessels, and loose cellular tissue (Fig. 11). The lymphatic glands are
important on account of the occurrence of lyrapho-sarcoma and other glandular
enlargements which may form mediastinal tumours.

DuLNESS WITH AN IRREGULAR OUTLINE is referred to in the italicised
remarks on diagnosis preceding § 46.

If, on percussing over the sternum, ^ or just beside it, the preecordial
dulness is found to be increased irregularly upwards — the morbid con-
dition may be Pericardial Effusion, Enlargement of the Left
Auricle, Retraction of the Lung, an Abdominal Swelling pushing
UP THE Heart as a Whole, or Aortic Aneurysm or some other
Mediastinal Tumour. The two last named are generally to be dis-
tinguished sooner or later by the presence of pressure symptoms (p. 93).
If possible, a skiagram should be taken.

Iff on auscultation over the abnormal dulness near tlie base of the hearty
there is a reinforced or ringing second heart sound — perhaps a
systolic or diastolic murmur — the disease is probably Aneurysm of the
Aorta.

§ 53. Intrathoracic Aneurysm. — ^Aneurysm of the aorta is undoubtedly
the commonest of intrathoracic tumours. In regard to the anatomy
of this serious and important malady, the student should study Fig. 11

The arch of the aorta is the favourite seat for aneurysmal dilatation.
Its shape and the fact that it is subject to continuous strain make it sur-

^ Remember, in percussing over the sternum, the note elicited is of a much higher
pitch than that just beside the sternum.

1 5S ] INTRATHORACIC ANEURYSM 91

prising that the malady is not even more frequent. Any part of it may
be affected — the ascending, transverse, or descending part of the arch.
The dilatation may assume either a fusiform or saccular shape, the former
being the more frequent. Fusiform dilatation arises as a rule in the first
part of the aorta, and may lead to stretching of the valves and aortic
incompetence. The fusiform aneurysm gives rise to practically no physical
signs, and the ensuing description refers, unless otherwise stated, to
saccular aneurysm. It may make its way in various directions, and it
is extraordinary how bones, cartilages, and other hard structures, may
become eroded and absorbed under its pressure. One of the earliest
results of aneurysm near the root of the aorta is cardiac hypertrophy, but
this may not occur at all when it involves other parts. According to its
position, aneurysm of the aorta may be either very easy or very difficult
to detect. If it involves the first part of the aorta, near the yron^ of the
chest, it is soon revealed by definite physical signs. If the second or third
parts of the arch are involved, and the tumour extends backwards, there
may be no physical signs, and even the pressure symptoms may be obscure.
Thus the clinical manifestations belong to two categories — physical signs
and pressure symptoms ; and we have two varieties of aneurysm : (a) The
aneurysm of physical signs, when the first half of the arch is involved ;
(6) The aneurysm of symptoms (that is, pressure symptoms), when the
SECOND HALF of the arch is involved.

The Symptoms Common to aortic aneurysm in all positions will be con-
sidered first, because these are the symptoms which will probably first
attract our notice. Then we will turn to certain others special to the first,
second, and third parts of the arch respectively.

Symptoms Common to All Positions :

1. Dyspnoea is often one of the earliest complaints which the patient
makes. When it is due to pressure on the trachea, as in aneurysm affecting
the transverse portion of the arch, it is persistent and stridulous in char-
acter. When it is due to pressure on the anterior pulmonary plexus, as
in aneurysm of the first part of the arch, it is often paroxysmal.

2. Cough is generally present and has a characteristic brassy sound
(gander cough). Pressure upon the recurrent laryngeal nerve is common,
with consequent paralysis of the left vocal cord, and there may be hoarse-
ness or even aphonia from the same cause. Paralysis of the left vocal cord
in the absence of central nerve lesions, practically always means aortic
aneurysm. Laryngoscopic examination should be a matter of routine
in all suspicious cases, because abductor paralysis occurs before com-
plete paralysis, and the former may be unattended by any alteration of
voice.

3. Pain in the chest is another common symptom. It may occur in
attacks of an anginoid character, shooting down one or both arms, usually
the left, especially in aneurysm of the first part of the arch. The pain
may be neuralgic when there is pressure on nerves ; or it may be of a dull
boring charact>er when due to erosion of bone, such as occurs in connection

92 ANEURYSM OF THE AORTA [ f 6S

with aneurysm of the descending arch.^ Short of definite anginoid attacks
of this kind, patients with aortic aneurysm are liable to feelings of suffo-
cation, constriction, or " spasm " in the chest, and nameless dreads come
over them from time to time without cause. Such attacks may in many
cases be brought on by bending the head backwards, or by any movement
which stretches the neck. I have known patients with dilated and rigid
aorta suffer frcm the same symptoms.

4. A reinforcement of the aortic second sound is the most constant of
the auscultatory signs of aortic aneurysm. It is sometimes spoken of as
a " ringing " second soimd.

5. The diastolic shock or thud is an equally important sign. It is felt
by the hand or the stethoscope, and is synchronous with the second sound.

6. Inequality of the radial pulses is a fairly frequent symptom. It is
present whenever the aneurysm is so placed as to cause a difference in the
arterial pressure in the great vessels which spring from the aorta. The
typical aneurysmal pulse occurs in the one just beyond the sac, and its
characteristic is a loss of the pulse wave, the blood flowing in one continuous
stream.

7. Inequality of the pupils occurs frcm pressure on the sympathetic.
In the early stage the irritation of the nerve causes dilatation of the pupil
on the same side. Later on there is paralysis, with contraction of the
pupil, accompanied sometimes by vascular dilatation and unilateral
sweating of the face and neck.

8. The heart may be displaced when the aneurysm is large, usually to
the left. It is sometimes hypertrophied.

(a) Sjonptoms peculiar to aneurysm of the ascending or first part o!
the arch. Aneurysm of this part of the arch is usually easy of detection,
and in marked cases the Physical Signs are unmistakable, (i.) On auscul-
tation, an accentuated second soimd is usually to be heard ; and in a large
number of cases, where the dilatation involves the valvular orifice, a
diastolic murmur is also heard. Over the site of the aneurysm a systolic
murmur is always present, and this is frequently present also at the aortic
area. Thus, a double murmur at the aortic area is found in many cases,
(ii.) Any percussion dulness present is continuous with that of the heart.
It usually extends to the right of the sternum, b\it this depends upon
whether the aneurysm makes its way forwards or not. The left heart
gradually hypertrophies, (iii.) On palpation, the diastolic shock is very
characteristic. Sometimes there is a thrill felt also in the suprasternal
notch, (iv.) When the aneurysm is so large as to form a tumour, the
swelling expands laterally with each systole of the heart. The accompany-
ing erosion of the sternum may be very painful, (v.) The right bronchus
may be pressed upon, leading to diminished or absent respiratory murmur
(R. M.) of the right lung. In severe cases there may be pressure on the
superior vena cava, with oedema of the neck and arms, (vi.) The dyspnoea

^ A case is mentioned in the footnote to §23 in which this was almost the only
symptom.

}sa INTRATHORACIC ANSUSYSM D3

is paioxyamal ; and the right tecuireitt laryngeal nerve may be involved,
with right laryngeal paralysis.

(6) The symptoms of aneurysoi of the second oi transrene part ol the
arch may be equally easy to detect when it makes its way forwards.
But when the posterior part is affected it may present considerable diffi-
culty in diagnosis, especially from other intrathoracic tumours, (i.) The
dyspnma may be either paroxysmal or continuous, with inspiratory stridor,
owing to the pressure upon the trachea, (ii.) Pressure upon the left
bronchus may lead to diminished breath sounds in the left lung, and
^mptoma {2) and (5) above are specially marked in aneurysm of the
transreise arch, (iii.) Tracheal tugging is a very characteristic sign of
aneurysm in this situation. Standing behind the patient, hold the cricoid
between the finger and thumb, and press gently upwards, the patient
sitting in a chair erect with the chin up (see Fig. 23). In this way the
pulsation is transmitted by the trachea to the hand, (iv.) The physical
signs — which are in this situa-
tion less marked, or may be
absent — consist of a thrill felt
on palpating the suprasternal
notch ; dulness on percussion
over the manubrium, con-
tinuous with that of the heart,
and extending from the middle
line to the left of the sternum ;
and auscultatory signs are de-
scribed above — (a) (i.).

(c) The symptoms of aneu ■
rysm affecting the dMcendini;
aorta may be very obscure,
(i.) Intense pain in the back is
the most common symptom,

and there may be no other for a long time [case in footnote, g 2:}). The
pain may pass to the side, following the course of an intercostal nerve,
(ii.) Other pressure symptoms, such as dysphagia, from pressure upon the
(esophagus ; wasting, from pressure upon the thoracic duct ; disease of
the left lung, from pressure upon its bronchi ; and any of the other symp-
toms mentioned on p. 91. (iii.) If the swelling enlarges, physical signs to
auscultation and percussion may become apparent in the left (occasionally
the right) scapular region ; and in advanced cases there may even be a
pulsating swelling without the knowledge of the patient. Osier found
that in such cases there is absence of pulsation in the femoral arteries.

Etiology.— (I) Aortic aneurysm is far more frequent in men than in
women, especially those in the prime of life — namely, between the ages of
thirty-five and fifty. (2) It is especially frequent among soldiers and
those who do laborious work. This liability has been attributed to the
wearing of belts and the like, but it is probably due to the fact that these

94 ANEURYSM OF THE AORTA [ § 6S

classes are subjected to sudden and severe muscular exertion and heart-
strain at certain times. It also occurs among blacksmiths for the same
reason.

(3) Both syphilis and alcohol are potent agencies in the production of
arterial degeneration. Alcohol acts probably in two ways — partly by
predisposing to degeneration of the aortic walls, and partly by over-
stimulating the heart from time to time.

(4) As an exciting cause some cases of aneurysm date from a period of
overexertion, exposure, and destitution, or from an injury.

Diagnosis, — The diagnosis of a deep-seated aneurysm is sometimes as
difficidt in the early stages as it is easy when the aneurysm is situated
superficially. The diagnosis from cardiac vcdvular disease and other
causes of cardiac hypertrophy (§ 43) is made by the occurrence of the
pressure symptoms. Many of the local signs of a saccular aneurysm may
be produced by a dilated and rigid aorta, but here the pressure symptoms
are wanting. The throbbing aorta of aortic regurgitation is apt to be mis-
taken for aortic aneurysm, and it is sometimes impossible to differentiate
these conditions. The throbbing aorta in Graves' disease and severe cases
of anaemia may also give rise to difficulty. Mediastinal growths, on the
other hand, may have the same pressure symptoms as aneurysm, and may
only be diagnosed by the absence of the physical signs referable to the
heart. There is no murmur on auscultation over the dull region, the area
of dulness is usually not so limited or defined, there is usually no expansile
pulsation over the tumour, and there are signs of collateral circulation.
Finally, the course of mediastinal tumours rarely lasts longer than eighteen
months. Radiography is very valuable in the diagnosis of the presence
and nature of intrathoracic tumours.

Prognosis, — By treatment much can be done to prolong life, and the
patient may live a good many years if his occupation does not necessitate
much exertion. Death may occur in four ways — from rupture, exhaus-
tion, cardiac failure, or complications. The rupture usually leads to a
sudden and copious hcemorrhage, which terminates life ; but sometimes
there is a slight leakage, which may recur at intervals of a few days.
With aneurysm of the ascendirhg aorta rupture usually takes place into the
pericardium, pulmonary artery, or superior vena cava ; with aneurysm
of the transverse arch, into the trachea (a very frequent situation) or into
the bronchi ; and, when the descending aorta is involved, the blood usually
finds its way into the pleura or oesophagus. The process may be so
gradual that there is no sudden onset of symptoms, such as dyspnoea, or
cyanosis, or bleeding, and death may not take place for some time. But
generally, as in the cases just narrated, it is copious and sudden, death
speedily ensuing. The severity of any case is measured to some extent
by the amount of dyspnoea present and the rapidity of the evolution of
symptoms. Other consequences or complications are due, for the most
part, to the effects of pressure — such as collapse or a low form of pneumonia
of the lung, hydrothorax, and oedema of the head and neck.

§ 64 ] OTHER MEDIASTINAL TUMOURS 96

Treaiment, — The indications are three in number : (a) To lower the blood-
pressure ; (6) to slow and steady the heart ; and (c) to increase the blood
coagulability in the hope that laminated clot will form in the sac. Absolute
rest in bed must be enjoined. This alone may accomplish very con-
siderable relief, and there is no doubt that some of the extraordinary
results claimed foi certain remedies have been due to rest. Much can be
accomplished by diet. It should be of the smallest quantity consistent
with life. Tufneirs'dietary^ is based on this fact, and in it only 8 ounces
of fluid and 10 oimces of solid are allowed per diem. It must be persevered
in for three to six months. The good derived from this dietary mainly
depends on the reduction of fluid. Drugs should be employed to steady
the heart and reduce the tension (Pulse, § 61). There is, however, one
remedy which is undoubtedly capable of materially improving thoracic
aneurysm — viz., iodide of potassium in large and gradually increasing
doses, commencing with 20 grains, three or four times a day.

Calcium chloride in large doses, in view of its known power to increase
coagulation, is worthy of trial. The digestive organs often need attention.
For the pain, morphia, atropine, or belladonna, internally or in the form
of a plaster, are used ; if of anginoid character, nitroglycerine. Even if
the dyspnoea is very urgent, do not perform tracheotomy imless it is due
to bilateral laryngeal paralysis. If there be an external swelling, some
elastic support is needed. Calomel is valuable for high arterial tension ;
aconite for palpitation. For venous distension or severe dyspnoea vene-
section may be performed. Surgical measures have been adopted from
time to time in the treatment of superficial aneurysms, but they are not
free from danger. Of such we may mention acupuncture, galvano-
puncture, and the injection of coagulating fluids such as perchloride of
iron (a dangerous procedure). Distal ligature of one of the great vessels
sometimes leads to improvement, especially if it is involved in the
aneurysm.

Other Mediastinal Tumours.

§ 64. The Symptoms of Mediastinal Tnmonr belong to three categories — namely,
(a) the signs of displacement of organs ; (b) the physical signs of tumour ; (c) the
symptoms of pressure. There are also {d) certain symptoms special to the different
kinds of tumour.

(a) The displacement of organs is sometimes the first intimation we receive. The
liver is rarely displaced, but the lungs and heart are often pushed to one side, and the
apex- beat may be found in the axilla.

(6) The physical signs of tumour appear sooner or later on the anterior or posterior
aspects of the chest, and consist of : (1) Dulness on percussion, corresponding to the
position of the tumour ; (2) auscultatory signs, which differ somewhat with the
position and nature of the tumour. If it be solid, the breath sounds will be tubular
and perhaps differ on the two sides, and there may be an increased conduction of the
heart sounds. If it contain fluid (such as aneurysm or, more rarely, hydatid) there
will be a diminished respiratory murmur, and in the case of aneurysm a characteristic

^ The solids may consist of wcll-cookod meat or fish and biscuit, and for the fluid
10 ounces of milk are permitted per day. From 12 ounces to 18 ounces solid may bo
permitted, but the fluid must not exceed 16 ounces. It must be combined with
absolute rest, and drugs are better avoided.

96 ANEURYSM OF THE AORTA [§54

murmur (§ 53). (3) Ausculto-percussion will aid in dofining the boundaries of the
tumour. (4) Radiography is used for defining the nature and position of mediastinal
growths.

(1) Dyspnoea always appears sooner or later, and may be of a type peculiar to
mediastinal tumours when there is pressure upon the trachea ; it has a stridulous
character, which resembles tubular breathing heard without the aid of the stethoscope.
The breathlessness is often paroxysmal or asthmatic when there is pressure upon the
heart and cardiac plexuses ; or it may be of a Cheyne-Stokes nature. But the char-
acter of the dyspnoea depends upon whether it is the heart, the great vessels, the
bronchi, or the nervous apparatus of the heart, lungs, or laiynx, which is pressed upon
by the growth of the tumour. •

(2) Cough, sometimes of a laiyngeal brassy character, is also present, and it is
accompanied by expectoration if , as is usual, there is also bronchitis or congestion of
the lungs. There may be laryngeal paralysis from pressure upon the recurrent branch
of the vagus, and hoarseness, or even aphonia, may result

(3) Cardiac and circulatory symptoms, such as palpitation, cyanosis, or a difference
in the pulses of the two sides in the neck or radial arteries. There may be signs of
collateral circulation, with enlarged superficial epigastric and mammary veins.

(4) Dysphagia, from pressure on the gullet, is present chiefly with posterior media-
stinal growths.

(5) Inequality of the pupils may appear, owing to pressure on the sympathetic.
Usually the pupil on the affected side is contracted from paralysis of the sympathetic,
but it may be dilated during the stage of irritation.

(6) Pleuritic effusion occurs if there be pressure on the thoracic veins or if there be
growth in the pleura.

(7) The inferior vena cava is rarely compressed, but lividity or oedema of the head,
neck, and arms may occur from pressure on the superior vena cava.

(8) In suspected tumour of the anterior mediastinum, it is well to remember that
when the head is thrown back, the veins of the neck become distended, owing to the
increased thoracic pressure producing venous obstruction. Dyspnoea is marked, and
the sternum may bulge forward.

(9) Pain down the arms and in the back occurs when there is pressure on the spinal
nerve trunks.

{d) Causes. — There are certain symptoms which are special to the nature and
situation of the tumour. There are five clinical groups of tumours, in addition to
aortic aneurysm.

I. Malignant Tumours, which may be primary or secondary. If, in addition to
the above physical signs, the expectoration present a constant prune-juice character,
aud if on paracentesis a bloody fluid is drawn off, the presumption is strongly in favour
of malignant tumour. The fluid may contain colls recognisable as malignant. Out of
520 cases of mediastinal tumour, Hare^ found 134 were cancerous. Cancer of the
mediastinum is the commonest mediastinal tumour, because it is usually secondary
to cancer of the lung or oesophagus. In the latter case it is situated in the posterior
mediastinum. Primary cancer, as of a bronchus, is rare, and tends to affect secondarily
the anterior mediastinal glands. Sarcoma, especially lympho-sarcoma, may start in
the mediastinal glands as a primary growth, or originate from the pleura and from
the thymus remains. Primary sarcoma is most frequent in the anterior mediastinum.
If secondary in origin (as when the abdominal viscera are the seat of the primary
tumour), it occupies chiefly the posterior mediastinum. In primary mediastinal
sarcoma enlargement of the glands in the neck and elsewhere may occur.

II. Innocent Mediastinal Tumoubs, though more rare than the foregoing, are some-
times found in the mediastinum — e.g., fibroma, dermoid cyst, hydatid. lipoma, gumma,
and enchondroma, the latter growing from the sternum, are also occasionally met with.

III. Enlabgement op the Mediastinal Glands. — ^With these there is often
dulness posteriorly in the upper half of the interscapular space, but occasionally there

^ Hare (" Mediastinal Tumours," Philadelphia, 1889) found out of 520 cases, 134
were cancer, 98 sarcoma, 21 lymphoma, 7 fibroma, 11 dermoid, 8 hydatid, 115 sup-
purative mediastinitis.

§54] MEDIASTINAL TUMOUR 97

is dulness over the sternum. Paroxysms of coughing, *' oroupy " or like whooping-
cough, may be present, together with stridulous breathing from pressure upon the
trachea. The eausta of enlarged bronchial glands are :

(a) As described above, malignant dUeaae of the glands is the most common cause
of enlargement.

(6) TtAarcU, which is generally secondary to tubercle of the lungs. It is more
common in children than in adults. The condition may be suspected when con-
current disease of the lungs is present, and symptoms such as the above, arise. If the
glands suppurate, sweatings and intermittent temperature become more pronounced
than when the lung only is diseased. An abscess may form and open into a bronchus
(compare IV. below).

(c) Lymphadenoma (Hodgkin's disease) may start in the anterior mediastinal glands.
Hare mentions twenty-one cases which ho included under the names " lymphoma ''
(lympho-sarcoma) and " lymphadenoma.'* Lymphadenoma cannot be diagnosed
with certainty from lymphoma unless the ordinary symptoms of Hodgkin's disease be
also present — viz.. (i.) enlargement of the glands in other parts of the body; (ii.)
attacks of pyrexia.

(d) Bronchitis and the pneumonia which complicates measles, influenza, and whoop-
ing-cough, are often attended by enlargement of the bronchial glands, which may
occasionally be recognised behind the sternum in children.

(e) Whooping-cough, without bronchitis or other disease of the lungs, may give rise
to swelling of the bronchial glands, although the condition may be hard to make out.
Some observers consider that it is the pressure of these glands which causes the
paroxysms of whooping-cough.

IV. SuppiTRATiVE MEOiASTnoTis (absccss of mediastinum) lb a rare condition
which may afifect the anterior or posterior mediastinum, or both, but more often the
anterior. (L) The most prominent symptom is pain, in the site of the inflammation,
or passing down the nerves pressed upon. (iL) Dulness, with cedema and redness, may
be present over the upper part of the sternum if the disease be in the anterior region,
or over the dorsal spines if in the posterior mediastinum. Pulsation communicated
from the aorta may be present, and lead to a diagnosis of aneurysm, but the pulsation
is not expansile, and fluctuation may be felt, (iii.) Pyrexia is present, usually of a
hectic type, with the rigors, sweats and weakness which attend all deep-seated inflam-
mations, (iv.) The presence of leucocytosis is an important diagnostic feature. The
causes of the acute form of mediastinitis are trauma, erysipelas, and the eruptive
fevers. The chronic form is usually due to tuberculous disease. It may rupture in
various directions.

V. Enlarosmbkt of the Thymus. — A certain degree of enlargement is normal to
childhood, and may cause dulness over the manubrium. It begins to decrease after
the second year of life, and should have disappeared by adult life. In the status
lymphaticus (§ 30) the thymus persists in adult life. An enlarged thymus is also
foequently found in Graves' disease, and rarely in Addison's disease, myxcedema,
mjrasthenia and rickets. Inflammation, oedema, and tubercle may afifect the gland.
Tumours may occur — cysts, sarcoma, rarely epithelioma, lymphoma and lymph-
adenoma.

Prognosis, — In all cases of intrathoracic tumour which are large enough to produce
symptoms the prognoss is unfavourable. Moreover, all of these conditions entail
much sufifering to the patient. Malignant tumours are fatal in six to twelve months,
depending upon the site and progress of the growth. Innocent tumours may last for
a long time. Syphilitic, tubercubus, and simple inflammatory glandular enlarge-
ments may recover under treatment, but even in these no confident prognosis of
recovery can be given in any case. Suppurative mediastinitis may open externally,
and run a course of a few days or weeks only ; other cases are chronic, and last for
yearsp or lead to pulmonary gangrene and oUier serious complications when the pus
bonows into adjoining organs. An enlarged thymus may lead to sudden death
&om pressure upon the trachea.

Treatment in intrathoracic tumour is almost wholly palliative. For aneurysm,
see § 53. Abscesses, hydatids, or growths connected with the sternum may be dealt
with by the surgeon in some cases.

CHAPTER V

THE PULSE AND ARTERIES

§ 66. The Meaning of " The Pnlie."— By the term *' pulse " is understood the expansile
sensation communicated to the finger by the alteration in the shape of the artery,
due to the momentary increase of blood -pressure which takes place during the systol<3
of the heart, and which is transmitted to the periphery in the form of a wave. It has
been shown that there is no dilatation of the artery ; the increased output of blood for
the moment raises the blood-pressure, and alters the shape of the channel from an
oval to a circle. The examination of the pulse is of extreme importance, not because
it has a set of diseases of its own, but because it affords us so many valuable practical
hints about the diseases of other organs, and about the general condition of the
patient. " Many of the indications obtained from the pulse do not depend upon a
comprehension of the circulatory conditions which the varieties of the pulse denote,
or, indeed, upon a knowledge of the circulation at alL Observant physicians before
the time of Harvey could gauge thoroughly the state of the patient in fever from the
pulse, and it is not for the purpose of estimating the movement of the blood that we
ourselves, in a case of fever, count the beats and note their force and volume. We
calculate from the data thus obtained the strength of the sufferer, and the effect upon
him of the disease. On the other hand, it is only through a knowledge of the con-
ditions which govern the circulation that such facts as the connection between kidney
disease and cerebral h»morrhage can be understood, and that the prognostic signifi-
cance of the hard pulse, which betrays this connection, can be appreciated." ^

For the production of the pulse three factors are requisite : (i.) The con-
tractions of the ventricle, which determine the frequency and rhythm of
the pulse, and to a large extent its force ; (ii.) the elasticity of the large
vessels ; (iii.) the peripheral resistance found in the arterioles and capillaries.
These three factors must always be considered in studying the pulse.

§ 56. dinioal Investigation. — ^It is preferable not to examine the pulse
until the preliminary excitement occasioned by the doctor's visit has sub-
sided ; and in all accurate records the pulse should be noted under similar
conditions as regards the posture of the patient, time of day, relation to
meals, etc.

The radial pulse is the one usually selected for examination, since it is
easily accessible and lies against a bone. But the pulse can be observed in
other situations — e.gr., the temporal, dorsalis pedis, or popliteal arteries.
Three fingers should be placed along the course of the artery, the index
finger next the heart, and allowance shoidd be made for much adipose
tissue. The different means of eliciting the several features will be dealt
with below. When feeling the pulse, its special features may often be

1 Sir William Broadbent. " The Pulse." first edition, p. 76. London. 1890.

i M ] CLINIC A L IN VEST 10 A TION 99

brought out more fully by holding up both wrists with the fingers on the
pulses. Only experience and comparison between all types of pulse can
give to the physician the necessary aptitude for observation and correct
inference. It is impossible here to enter upon all the complex data of the
circulation, but the leading practical points which are of use in clinical
work will be indicated.

A complete observation of the pulse should comprise six features, the
first four being the most important.

1. Rate and Rhythm (i.e., regularity). — The rate of the pulse per minute
is easily calculated by the watch, and in making this obserx^ation it should
be remembered that a physiological acceleration occurs after any exertion,
excitement, or after a meal, or may even be caused by nervousness on
the visit of the doctor. The pulse is faster in the evening than in the
morning, and it is faster by about eight beats per minute in an upright
than in a recumbent posture.^ If the pulse be irregular, the type of the
irregularity (vide infra) must be noted.

2. The Farce or strength of the pulse depends largely upon the force of
the heart beats, and is best measured by its com'preasibUity — the finger
next the heart presses the vessel until the wave is no longer appreciable
to the other fingers. By the amount of pressure required to obliterate
the wave, the force with which the blood is propelled from the heart can
be estimated. A " full bounding pulse " is one which has strong pulsations,
but it is not necessarily one of high blood-pressure. Indeed, a full bounding
pulse may occur in fevers where the blood-pressure is generally low. The
strength of the pulse is measured by the force or strength of the pidse wave.

3. The Character of Each Beat is observed by noting (i.) whether the
pulse wave rises suddenly or gradually ; (ii.) the duration of the beat,
whether long or short ; and (iii.) whether the decline is abrupt or gradual.
It is important to note the presence or absence of dicrotvtm, which is a
marked feature in low tension (see § 62).

4. The state of the blood-pressure or arterial tension is perhaps the
most important pathological feature of the pulse, and it is estimated by
the degree of fulness of the artery between the pulsations. Normally the
vessel is hardly felt between the beats if the wall is healthy. The vessel
should be rolled transversely under the fingers, and, if the arterial tension
is high, it stands out like a cord between the beats.

5. The Size of the Artery and the State of its Walls will require fuller
consideration later on, but it is important to note these features, because
an artery of small size may give the impression of a weak pulse. The

^ The pulse is faster in the female than in the male, and it varies considerably at
different a^, tiius :

in the foetus and new-bom infant its average rate is 140 per minute.

Under 1 year „ „ 120

Under 8 years „ „ 100

From 7 to 14 „ „ 90

From 14 to 21 „ „ 80

From 21 to 65 , „ 70

In old age ,. ,, 80

100 THE PULSE AND ABTERIES [JM

thickneaa of the wall must also be noted, because a thick-walled artery
may give the impreBsiou of high arterial tension.

6. The piUae of both Radial Arteries should be compared, so that any
abnormalities may be detected. It should be part of the routine to
examine both pulses, as by this procedure we may detect the existence of
unsuspected disease, such as aneurysm or other intrathoracic tumonra.
Abnormalities such as a more or leas superficial position of the radial on
one aide or the other exist more frequently than is supposed.

It will be advisable to consider the Pulae under five headings : ■ I.
Rapidity; II. Infrequency; III. Irregularity; IV. High Blood-Pressure
(or Arterial Tension) ; V. Low Arterial Tension, They are relatively of
very different importance. Altoi-ations of tension are of the greatest

Fia. H. FiQ. as.

Fl«. M.— NOKMAL PHLSS TEioiSQ, taken wltb tbe »othQr'i modiflcMion ot Dndgton _ „,_^ .

graph. Bate eg ; pceuDie (boat ! ooncea. Fig. ES.— -Norual PVlSI TkaCiXo (Fig. £4)

"1, with th« namw of the iirindp«[ pftTta. The dletolic (or Jiortlc) notch indlatea

~ of Uie sigmoid viivea, and therefore the lenoluation ol the ventricular >r>ta1e and

jicement of the ventricular dlutole. The diailolic line li that part of the tracing

froiD the dicrotic notch to the nent percusilon vave.

moment, and irregularity comes next. The caosei of these will be
considered ; their treatment, with the exception of high and low tension,
belongs to the causal conditions.

The Sphvohoobafr is an inBtmmont eniplojod to obtain a record on paper of tho
characteTa of the palge. The linit one uBod was that of Mare;. In this instruniont a
pad placed over the pulse is connected with the short arm of a lever ; tho long arm,
which magnifies the pulse wave, is sharpened to a point, and makes a tracing on
smoked paper.

The handiest instrument, however, is that of Dudgeon. This is n littlo instrument
which is strapped on to the wrist. Some years ago Weiss mode for mo a modification
of the latter whioh can be used without a strtip — on appendage which I regard as un-
necessary, since the instrument can more readily, with a little practice, be steadied
and adjusted by the hand of the operator. The manipulation of any of these instru-
ments is easily acquired by experience. The chief precautions are : (i.) To place the
pad exadly over the artery, and it is of gieat assistance if the course of the Teasel has
been pravioDsly marked by an aniline pencil \ (ii.) the omounl of prteaun uned, and
the adjustment of the instrument, should be suoh as to obtain Uie most graphic

The SPBYGUOOitAU or sphygmographic tracing is very useful as a gmphic record
of the pulse, and to show the progress of the case from day to day ; but it does not
tdl na as much as the ednoated finger, and its readings can never bo quite aocuiate
because the exact amount of pressure exercised by the pad upon the artery cannot bo
known. Figt. 24 and 26 represent a normal pulse tracing, the principal named porta
of which it consiita being indicated in the latter. (1) Tbe jurautioa wave is abrupt
and vertical in proportion to the force of the ventricular oontiootion and invaraely

157]

RAPID PULSE

101

proportional to tho peripheFal rosiBtanoe. (2) The tidal wave is prominent in pro-
portion to the amount of peripheral resistance and the force of the ventrioolar con-
traction— ».«., when the arterial tension is high. When the peripheral resistance is
very low Uiere may be no tidal wave. (3) The dicrotic wave is pronounced and the
aortic fioM more marked in proportion as the peripheral resistance and the heart force
(i.e., tho arterial tension) aro low.

Many instnimonte have been devised for tho measitremekt of the BLOOD-PtiESSUBE,
tho most accurate of them would seem to be RrvA Rocci's Sfhyomomanometeb, a
modification of which is shown in tho accompanying figuro (Fig. 26). Hill and

Fig. 26.~Riva Bocci's Sphyomomanombtbr.

The armlet should be wrapped round the patient's arm above the elbow (the arm Bhoold either
be bare or at most covered only by a thin shirt) ; the armlet ihoald be ittrapped on, and it is im-
portant to see that it fits snugly. One end of the rubber tube should be attached to the armlet,
and the other end to the ciftero of the manometer, the inflator and liberating valve being in the
middle. The left hand should be used for feeling thie pulse, and with the inflating bulb in the right
hand, air should be pumped into the apparatus until the pulse at the writt ie felt to stop. The
pressure, as indicated by the manometer at which this occurs, should be rcNsd off, and then (by a
very slight turning of the milled head of the valve) allowed to decrease slowly, and the exact pressure
at which the pulse returns at the wrist should be noted. This will be the maximum systoUe pressure
in the brachial artery. After each observation the pressure in the apparatus should be released.
The maximum systolic pressme for an ordtoary healthy adult is between 120 and 130 milli-
metres of Hg approximately under fifty years of age, and between 130 and 145 millimetres in later
years. To obtain the so-called diastolic pressure with this instrument, after the pulse at the wrist
has been stopped, the pressure in the apparatus should be slowly released by a turn of the valve,
and the pressure at which the maximum pulsation of the surface of the mercury in the msnomotei
occurs should be noted. In taking repeated observations in the same patient, it is important that
the same arm should be used each time, and that the patient should always be in the same position

i.e., cither sitting or lying down.

Barnard's sphygmomanometer, used with a broad armlet, is also very good. There
are several portable modifications of the Riva Rocci sphygmomanometer now on
the market.

§ 67. Rapid Pnbe. — The rapidity of the heart-beat varies considerably
within the range of healthy and in many persons the heart may occasionally
beat 150 a minute for a short time without inconvenience. In infancy
the normal rate is 130, and this may continue in after-life.^ The pulse
is normally more rapid during the menstrual period and menopause, in

^ See footnote, p. 99.

102 THE PULSE AND ARTERIES [ f 58

the evenings and after meals. After a severe illness the pulse more easily
becomes rapid.

The pathological causes of quick pulse are numerous. Apart from
cardiac afEections, or Graves' disease, a quick pulse is relatively unim-
portant in the young. In general terms it is only a serious symptom
when met with in the latter half of life. It is very desirable in such cases
to obtain a sphygmographic tracing, for the danger of a quick pulse may
be fairly measured by the amount of dicrotism present.

1. In diseases of the valviUar structures of the heart the pulse is quickened,
more especially in mitral and aortic regurgitation ; and also in the later
stages of all forms of valvular lesion when cardiac failure conmiences.
In extreme dilatation, especially with auricular fibrillation, there is a
condition known as delirium cordis, where irregularity and rapidity of
action are combined. Foetal rhythm is also met with in dilatation (§ 44).
An insidious chronic endocarditis, before the occurrence of a murmur,
may be evidenced by tachycardia as the only sjTnptom for months.
This is especially the case in mitral stenosis ; Balfour^ mentions a case
in which the presystolic murmur appeared two years after the heart hurry
commenced.

2. In cardiac dilatation (apart from valvular disease) the pulse is
quickened, especially if accompanied by arterial atheroma or sclerosis.
In the latter half of life tachycardia is nearly always associated with
dilatation of the heart, the result of a degenerative change. Thus, one
of the earliest signs of the failure to compensate for the obstruction caused
by arterial disease is a persistent tachycardia. Quick pulse, indeed, is
regarded by some {e.g., Balfour, loc. cit.) as the leading feature of both
" irritable " and " senile heart."

3. Pyrexia is recognised as the most common cause of rapid pulse
when the heart is sound.

4. Various other toxic conditions increase the heart rate. The heart hurry
which attends chronic alcoholism is very eerious, as indicating fibroid or fatty
degeneration of the heart wall, or neuritis of the vagus. Tobacco first slows tho
heart, but in large doses paralyses the vagus ; hence excessive smoking may induce
paroxysmal tachycardia. Digitalis in large doses also paralyses the vagus (Bal-
four). Belladonna increases the rate, fulness, and force of the beat, and increases
the blood-pressure (Balfour), but in toxic doses it paralyses the vagus and produces
tachycardia. Tea and coffee may produce temporary heart hurry.

5. Many affections of the nerves, functional and organic, are attended by heart
hurry, usually transient, but sometimes persistent. Emotional rapidity of the
pulse is familiar to everyone. Paroxysmal tachycardia is described elsewhere (f 40).
Tumours pressing on the vagus may be evidenced by tachycardia, even if the tumour
be small ; a rapid pulse may, indeed, be the only symptom.

6. In Graves* disease tachycardia is often the earliest symptom, and in this disease
there may be throbbing in the whole arterial system, the heart sounds being clear
and distinct.

§ 58. Slow Pulse, Infrequent Pulse, or Bradycardia {i.e., slow heart),
is met with under several conditions. In health a slow pulse is normal
to certain individuals without any very obvious explanation, and without

1 " The Semle Heart," 1894.

f M ] SLOW FUL8E—8T0KE8'ADAM8 DI8EA8B 108

any other symptoms. Napoleon is said to have rarely had a pulse-rate
over forty. I have known a gentleman for twenty years, whose age is
now eighty-two, who has never, to my knowledge, had a pulse-rate over
fifty when in health : its average is forty. He has always enjoyed very
good health. In some families it is met with as a hereditary condition.
It is always well to verify an apparently slow pulse by listening to the
heart at the same time, for in some cases the infrequency of the pulse
may be due to some of the heart-beats not reaching the wrist. In disease
a slow pulse is of importance chiefly in heart and brain disorders.

1. In heart disorders a slow pulse without irregularity is uncommon.
It may, however, be met with in connection with the senile heart, where
it always indicates some degree of dilatation. Sclerosis of the coronary
arteries, atheroma of the aorta, and fatty or other degeneration of the
cardiac wall, may also be attended by bradycardia. It is one of the
cardinal symptoms of Stokes-Adams disease.

§ 69. StokM-Aiams DiMMe (Heart-Block) is a rare disease, first described by
B. Adams in 1827, characterised by a permanently slow pulse, with syncopal and
epileptiform attacks. The patients are usually advanced in years, complain of
dyspnoea, and have marked bradycardia, the puke-rate ranging from 20 to 40. Any
mental excitement is liable to bring on an attack. The breathing becomes stertorous,
the face cyanosed ; there is dilatation of both pupils, rigidity of the body, accom-
panied by clonic movement« of the limbs ; the pulse beats more and more slowly, and
finally ceases ; the jaw drops, and for forty to eighty seconds the patient is to all
appearance dead. No pulse is felt in either wrist, and on auscultation the cardiac
sounds are inaudible. Then a feeble sound is heard, followed by a stronger, and a
second later the pulse begins beating (one can feel the artery fill), the cyanosis lessens,
the pupils contract, and consciousness returns. Many such fits may occur in succes-
sion, from six to ten in a single night. There is no albuminuria.

Etiology. — ^This symptom-complex occurs in association with arterio-sclerosis and
myocardial degeneration in old people ; in young people with syphilis and coronary
disease. There is a blocking of the normal stimulus and wave of contraction from
the auricles to the ventricles, due to disease affecting the auriculo-ventricular muscle
bundle of His. During an attack there is cessation of the ventricular systole, whilst
the auriclee continue to contract.

TrtaimenL — Inhalations of strong ammonia may avert an attack. The general
condition requires attention. Strychnine and bromides are recommended.

2. If a slow pulse is associated with marked high tension, arterial scleroaia should
be suspected, even when no sign of arterial disease can be discovered.

3. Various gastric derangements are frequently associated with a slow pulse, probably
in a reflex manner. This is, perhaps, the commonest cause of slow pulse in children.
In adults it may be associated with gastric ulcer and carcinoma. In chronic dyspepsia
a slowness of the puke is usually associated with some amount of irregularity and
intermission.

4. Many nervous disorders may be associated with slow pulse. Thus :

(i.) If the temperature is raised, the arteries contracted, and the pulse slower
than normal, and if with this there be some irregularity in rhythm, and perhaps a
reduplicated second sound, in a child, we probably have to do with an early stage
of meningitis.

(IL) Cerebral tumour is another nervous condition associated not infrequently
with slow pulse. Here, however, it probably only occurs in the late stages, and as
a pressure symptom. Halberton mentions a case in which a violent blow on the
head was followed by a permanently slow pulse, with syncopal attacks, succeeded
by epilepsy. The post-mortem revealed narrowing of the foramen magnum.

(iii.) Various psychical disorders, such as melancholia, general paralysis, and
epilepsy, may ako be attended by slow puke.

104 THE PULSE AND ARTERIES . [ S 60

(iv.) An abnormally slow pulse has been obsezred in association wiUi spinal injuries,
especially a£Fecting the medulla and cervical regions.

5. Drugs, such as digitalis and strophanthus, slow the rate of the heart, and, if
irregular, steady its rh^iihm. Belladonna and tobacco at first slow the heart.

6. Slow pulse is also met with in toxic conditions, such as diabetes, jaundice, uraemia,
and poisoning by carbon monoxide.

7. In states of prolonged exJiaustion and ansemia, and in convalescence from acute
illness, bradycardia occurs.

§ 60. Irregolar Pulse (Airhythinia). — Many forms of arrhythmia have
long been recognised to occur. Recent work, especially by Dr. James
Mackenzie and Dr. Lewis, has thrown light on the causes and significance
of these different forms. The polygraph (§ 35) and electrocardiogram
records may be required to elucidate certain cases, but these are beyond
the scope of the average clinician. It is useful to remember that the
contraction of the heart may start in four positions : (i.) At the mouth of
the great veins, the normal or sinus rhythm ; (ii.) at the auriculo- ventricular
bundle, when auricle and ventricle contract simultaneously ; (iii.) on the
auricular side of the bundle, when the ventricle contracts independently ;
(iv.) in the auricular tissue. Arrhythmia is a sign of abnormal action
of one or other function of the cardiac muscle, and may be of trivial or
of grave import.

1. Clinically, irregularity of the pulse in the young is usually due to
sinus irregularity. The length of the cardiac cycle varies with respira-
tion ; the pulse beats are of equal size, without missed beats. The con-
dition is more or less transient ; rest and building up of the general health
are indicated.

2. The intermittent pulse is not infrequently met with in health after
meals, or as a constant feature, and it is restored to normal during exercise,
excitement, or pyrexia. In this condition a pulse beat is missed, occa-
sionally or frequently, after several regular beats. This form of irregu-
larity is due to an " extra systole " — i.e., the auricle, or ventricle, or both
together, start an independent rhythm, and so cause a premature small
pulse beat, followed by a pause. Sometimes the extra systole is not
capable of causing a pulse beat at the wrist. If the heart be auscultated
the physician will hear the characteristic two short sharp sounds indica-
tive of an extra systole coinciding with the absence of the pulse beat, or
with the small premature beat, at the wrist. Thus auscultation differ-
entiates intermittencv from heart block, in which condition no sounds are
audible over the heart when a pulse beat is absent. The patient may
experience no symptoms, or may be sensible of cardiac discomfort, palpita-
tion, or transient giddiness, which alarm him. Intermittency may occur
in neurotic states, or with dyspepsia, or a distended colon, or after tea,
coffee, or tobacco, when it is of slight import. It may also occur in con-
nection with alterations in the cardiac wall — e.g., in elderly people with
fatty or fibroid heart, when it is due to changes in the auriculo-ventricidar
bundle ; and after rheimiatism. It occurs also when digitalis has been
administered long enough. A variety of the intermittent pulse is

! a ] OAUSES OF IRREGULAR PULSE 106

described as the pulsus higeminus ; the beats occur in couples, a strong
beat being followed by a weaker one, after which there is a pause.

3. In advanced cardiac disease the disorderly pulse of auricular fibrillar
lion iq.v.) is of grave import. The beats are of varying size and intervals,
no two are alike, and they are usually very rapid. Distressing dyspncea
usually accompanies this condition, which occurs chiefly in mitral disease
and cardio-sclerosis. Rest and large doses of digitalis are indicated.

4. In the pulsus altemans the rhythm of the radial pulse is regular, but
there are alternate large and small beats. This condition indicates that
the contractile function of the heart is failing. It is a very grave sign in
fibroid hearts, and indicates the necessity of rest.

5. Irregularity may be due to failure of the conducting power of the
auriculo- ventricular node. The ventricular systole may drop out, and
thus the pulse misses a beat. This condition is rare. It may occur in
influenza and other infectious diseases ; in rheumatic hearts, in cardio-
sclerosis, and after digitalis. Heart-block is an extreme form of this
condition. On auscultation the heart sounds are found to be absent at
the time of the pause in the pulse. The pulse is usually slow, and Stokes-
Adams syndrome may develop.

In pfdsus paradoxus thero is completo, or ahnost oompleto, disappearance of the
pulse daring inspiration. It irdue to cither (1) an increase of the '' negative *' intra-
tboracio pressure which normally takes place at the end of inspiration, or (2) an
extreme weakness in the left ventricle, or to both. Maguire has shown that it can be
produced in even healthy persons at the end of inspiration by so contriving that the
negative intrathoracic pressure can be suddenly increased. It is met with in intra-
thoracic tumours, pleural effusion, modiastinitis, and adherent pericardium.

The jfuUua bisferiens is a rare and peculiar type of pulse occurring in some cases
of aortic disease (stenosis or regurgitation, and especially the latter). It is apt to be
confused with the dicrotic pulse, though it indicates neither increase nor diminution
of tension. A double beat is felt because the ventricle makes two distinct efforts
during the systole. It is distinguished from dicrotism by becoming more evident
by pressure, whereas the dicrotic pulse is obliterated by pressure.

The anacrotic pulse is a somewhat rare condition, resulting from high arterial
tension. In it the tidal wave is higher than the percussion wave. It is found in
some cases of aortic stenosis and aneurysm, where the ventricle has to overcome
abnormal resistance, and the blood cannot rush out in full volume during the systole.

§ 91. ffigh Blood-Pramire (or high Arterial Tension, as it used to
be called)^ is, in extreme cases, recognisable by palpating the radial artery ;
but the digital method is so unreliable that no attempt should be made
to gauge the blood-pressure except by means of an instnmient. There are
several of these on the market. The best for the consulting-room are
probably C. J. Martin's modification of Riva Rocci, or Oliver's alcoholic
instrument. There are others which are more portable. The sphygmo-
graphic tracing of high blood-pressure is shown in Fig. 27.

The normal blood-pressure varies with age and circumstance. It is
rather lower in women than in men, and lower in children than in women.
The normal blood-pressure in a healthy adult of about thirty years of

^ It is a common error to speak of " pulse tension,'' " high-tension pulse/' etc. It
18 not correct to say that a wave has pressure or tension, but the terms have become
sanctioned by custom.

lOfl THE PVL8B AND ASTBBIB3 I J «1

age may be taken as 120 millimetres Hg. The nonnat blood-piesanie
rises gradually after that period, so that at sixty years of »%e a. blood-
pressure of 160 millimetres Hg need not excite alarm. But at any age
a blood-pressure of 200 millimetres Hg or over is a distinct danger-signal.

The Symptoms which accompany high arterial tension, and which lead
us to suspect that condition, are very important, though somewhat
variable. They consist of (i.) headache, which may be frontal, occipital,
or vertical, accompanied by vertigo from time to time, and a constant
feeling of fukesa about the head, (ii.) There may be some lassitude,
disinclination for exercise, and depression, (iii.) Breathlessnesa on exer-
tion is common ; very often it is paroxysmal, and the patient thmka he haa
asthma, (iv.) Wakefulness, or sleeping by dozes, ia not uncommon.
High tension is rare in children, but these syinptoma occurring in adults,
especially in those past middle life, arc suspicious, and are confirmed, il
upon examination, we find the following physical signs : (i.) The pulse
revealing the above characters ; (ii.) on auscultation an accentuated
aortic second sound (some-
times accompanied by a
reduplicated first sound at
the apex) ; (iii.) later on,
if the condition persist or
frequently return, cardio-
vascular hypertrophy
supervenes.

Hg. 27.— HlOH TENaiON In a cine ot Chronic DHght's Th« CiiuMs o! high arterial

IMacue, with Albuminuric Retinitis, under the aae tenaioii are nutneroua. Among

"' ^: «■ ": B''''"*e- High len.101. 1> indict**! the prtrfiraoaiBff catMM heredity

iBiphlcally by (l) prominent ol the tidal wave "'"*' r""*?" 7 . •'

(oulew the »rteriei are very atheromatoua) ; (a) smaU- undoubtedly plays a most un-

iieM of the dicrotic wave, and ita occunence hlgli up portaDtpart. No age U exempt,

un tho diastolic lino : |3) eradaal (loping ot the but it is found far moie fre-

aiMtollc line toward, the next m-trokc ^^^^^j^ ^^ ^„j ^^ ^^j^ j^^

As regards sex, males are more

Bubj^l U> tho diueaoe, siiico thoy are mom exjiOBod to the dietetic and other influences
which raise blood -presBU re. Exciting causoa bring into opeiation one or more of tfaree
pathological factors— increaxed periphoral resistance, incioased cardiac force, or
increase in the volume of the blood. Tho exciting causes ai« as follova, arranged
aa nearly aa possible iu order of importance ;

1. Anything in tho mode of lite which loads io deficient oxygenation and tlimina-
lion of nilrogenoua wagU, such as : (L) Excosa of nitrogenous food ; alcoholic drinka
of any kind, even in moderation ; sedentary habits ; constipation. (2) Toxie eon-
dilimu of the blood act probably iu the same way. (I) Renal disease is a familiar
antecedent and accompaniment of high arterial tension, (ii.) Gout. High arterial
tension so frequently accompanies this condition that it is known sometimes as the
"gouty pulse." (iii.) The diabetes which occurs in peisoDs past middle life ia attended
by high tension, but not that more fatal form of diabetes which occurs in younger
aubjeole. (iv.) Plumbism, which is intimately connected with gout and renal disease.
(v.) Emphysema, and sometimes other lung conditions (probably by deficient
oiygeuatiou). (vj.) An semia sometimes, (vii.) Pregnancy. (3) Any condition lead-
ing to a per«ittetU contraction of the arterioles reaulte in high arterial tensioB. It is
highly probable that some of the above toxic conditions may act in this way.
(4) PUOufra, by increasing the volume of tho blood, may rcsalt in increased arterial
tension. (5) In cardiac hypertrophy there is a great tendency to high blood-p ""

! 6E ] HIGH BLOOD-PRESSURE 107

Whenever the heart beats more rapidly and more poweifuUy — as, for instance, during
excitement or during exertion — there must necessarily be a rise of pressure. This
is usually transient, but if frequently repeated, as in athletes, it may be a forerunner
of a persistent high arterial pressure. (6) In certain neuro-vascular diseases there
is a tendency to dilatation, and in others to spasm, of the peripheral vessels. In the
latter {e.g,, Raynaud's disease) there is a frequently recurring tendency to high blood-
pressupe.

Pathological Effects of High Blood- Pressure and Prognosis, — Temporary
high arterial pressure is not serious, but when it constantly recurs or con-
tinues over many months or years, it has grave results. By the physio-
logical law that increased function results in increased growth, there is
hypertrophy of the muscular tissues of the whole of the vascular system —
that is to say, hypertrophy of the heart and of the muscular tissues of the
arteries (Arterial Hypermyotrophy, § 68). This may be said to constitute
the first stage. If the increased pressure continue, a degeneration occurs
in the musctdar tissue of the heart and of the arteries (§ 67). The second
stage is manifested chiefly by the failure of the heart to compensate for
the increased peripheral resistance caused by the rigidity of the arteries.
Certain accidents are liable to occur as the result of high blood-pressure,
even when this is functional only. Chief amongst these is hsemorrhage.
A person with high blood-pressure may bleed from anywhere ; rupture of
the arteries into the internal capsule or other parts of the brain, rupture
of retinal arteries, hsematemesis, haemoptysis, bleeding from the nose,
bleeding from the gimis, are all common. When undue pressure on the
arterial system has been in operation for some time, changes take place in
the coats of the vessels ; in the larger vessels, such as the aorta, it leads to
atheroma ; in the smaller vessels, to sclerosis. Arterial disease of both
kinds is usually very patchy in its distribution. Thus, sclerosis of the
vessels in the renal area gives rise to granular kidney ; in the hepatic area,
to cirrhosis of the liver ; and in the vessels of the brain, to what are known
as senile manifestations.

The treatment of high blood-pressure in its functional stage is one more
of general hygiene than of drugs. Salines and mercurial purgatives are
of the highest value. Vaso-dilator drugs, such as the nitrites, have a very
transitory efEect (Fig. 28). If the blood-pressure, as measured by the
manometer, reaches an unduly high figure, venesection should be practised,
and the patient relieved of at least 20 ounces of blood. Hot baths, Turkish
baths, electric light baths, high-frequency currents, and, indeed, anything
which will dilate the cutaneous vessels, should be advised, but walking
exercise is probably the best. The iodides of potassium and sodium in
large doses produce good efiects on the blood-pressure.

§ 62. Low Blood-Ptessiire may be suspected if the pulse, when counted
with the patient erect, is rapid, and the rate falls 30 or 40 beats when the
patient is placed in the recumbent posture. As measured by the mano-
meter, 80 millimetres Hg is regarded as a dangerously low pressure.
To the examining finger the pulse comes up rapidly, rapidly declines, and
is very easily obliterated. In very low tension a double wave is felt, the

lOS

TEE PULSE AND ABTBJtlSS

[}U

second one being small ; this is known as the dicrotic paUe. A sphTgmo-
graphic tracing bIidwb an increase of the normal depiession (aortic notch)
before the dicrotic wave, and the dicrotic wave itself is more marked
than in a healthj pulse.
When the aortic notch
falls below the level of
the base line, the pulse
is said to be kt/perdicrolic
(Fig. 28, e). SympUmuoi
depression, lassitude,
prostration, and some-
times dyspepsia and
sleeplessness, occur in as-
sociation with low arterial
tension. Purgatives can-
not be well borne, and
the patient may feel
better when the bowels
are constipated. Capil-
lary ptiUation is some-
times met with in low
arterial tension, particu-
larly with aortic legui^-
tation. By drawing a
line along the forehead,
or lightly pressing down
the tip of the nail, the
alternate blush and pallor
due to the capillary pul-
sation is well brought
out. In extreme states
a pulse may even be
communicated to the
veins on the dorsum of
the band.

Causes. — In health a
persistent 8tat« of low
tension is sometimee,
though rarely, a heredi-
tary condition. It may
be foimd also after meals,
a warm bath or moist
warmth.

1. With cardiac mimt-
lar disease, in all phases
of failing compensation,

■inga showing [he e

MuUn B.,
nephritlB. i
In tbe Wi
B, Typical t

aged forty- H"

; puenchymatoiu
_ WlUUm Oalrdner

n Inflrmary, Glasgow, Auguat, 18fl5.

teiiaiOB. Tracing b showi the leducUos
ui U1IBUIU luHu IB gtaiiiB lodium nitiite In tour dmca
duilDB the twenty-lour boun. The remedy was continusi
and tradngi e and <i on succeBBlve dayi show the giadnal
redndlonof tenBlonelleeKd, They are nonaal eioepUng
for Hw esaggeratsd aorOo wave. In the hut traejng e a
l^ondltlon of STfebdiosotibii 1« ihown, the higb toniloa
havliu been entirely replaced by tbe oppotlte extreme

.,,._.... ..__„.j t.. ■.,. .y g (;|j_j|j^ ^^^ ^^ ^^ hoUlB-

JO] LOW BLOOD-PRESSOSE 109

there is low tension. The pulse of aortic regurgitation is so characteristic
that the lesion can be diagnosed by it. It conies suddenly up to the finger,
and as suddenly collapses. This has received the name of " stot^,"
" slapping," " water-hammer " or " collapsing " pulse, the pulse of unfilled
arteries, or Corrigan'a pulse, after thejname of the phyaician who first
described it (Fig. 30). It is best brought out by feeling the radial while
the patient's hand is held up vertically on a level with the head. In thia
condition tie radial pulse is
distinctly postponed — that
is to say, the pulse at the
wrist occurs later than the
apex-beat. Moreover, the
srtery in aortic iegu^t£-
tion is lai^, in contradis-
tinction to aortic stenosis, ^ _ .^ -^ .

, ,, „' Pig. !«.— Low-TiHSiox.PruB Tk*oi!io. from ■ ««« o!

where the artery is small. Enuno F«ver, ihowiiw muked DioBoruit. Patl«nt

The sphygmographic tracing *^^ thirty-«Yen.

of the " water-hammer " pulse shows a long percussion stroke, scarcely any
tidal wave, with a sndden down stroke, broken only by a small dicrotic
wave. In oaaes of a double aortic murmur, this pulse is of great diag-
nostic significance. If the pulse has a distinctive " water-hammer "
character, the systolic murmui is due not to aortic stenosis, but simply
to roughening of the valves or atheroma of the aortic wall.

2. The pulse is of low tension in all advanced states of cardiac failure

3. Without o^anic heart disease low blood- pressure is met with in
neurasthenia, in Addison's disease, tuberculosis, and in all staUs of ei-

Fl(. 9a.~WATBK-EAlIifKB Plil»,— Tradng (Uken by l)r, Renlnald E, Hnnaon) frnm ■ man,
and tUr^-fooi, wltb tyilcal aartifl regorgltUlaD, UKompuUed by very grwt caidisc hyp«r-
tn^Ay Cbovine hMit). WeU-mukad eapUlarr poliatlon >nd lettnol pulutlou vtie prtaenl.
Trpfol wdlaiaina or watw-tummer pobe. He bad Iwd anslnold lUacks, which neie leLieved
bf lodiam nlbrite. At tba time tradns was taken pulio wu Si, reapliation 21, and blood-
pnanue (taken by HIU and Baniard'i Initrnment) KO.

iatMttoH and debility, such as are caused by over- exertion, physical or
mental, deficient and bad food, or anxiety — conditions in which vaso-
motor paresis might occur. In its extreme form it is recognised clinically
u sui^ical shock or collapse. It is common in adolescents and causes an
albuminuria (owing to congestion of the kidneys), which has no pathological
significance (§ 291).

^1. Low blood- pressure is also met with in all atlhenic varietia of fever,
especially enteric fever and peritonitis (Fig. 29).

110 THB PULSE AND ARTERIES [ K 6S,.64, 66

Treatment depends upon the cause. The food should be nourishing
and easily digestible. Change of climate is often beneficial. Iron, arsenic,
quinine, strychnine, and digitalis are all useful. In collapse warmth should
be applied to the surface and pituitary extract injected hypodermically.

§ 68. The Patoe in Relation to VtogaoiaB and Treatment of Diieaie. —
In acute febrile diseases a full bounding pulse is usual, and its absence
warns us that we are in the presence of an asthenic and more dangerous
type of case. It is in fevers also that the pulse is our chief guide as to
whether alcohol should be administered or not. In enteric, for instance,
if the pulse is weak and the vital powers flagging, stimulants are called
for, but not otherwise. This was Murchison's rule. In chronic affections
the pulse is not so valuable an indication of the patient's general condition.
Perhaps the most important fact to bear in mind is that in the aged, and,
indeed, all persons past middle life, the pulse should be carefully watched
from time to time, because a constant high pressure is the main cause of
arterial degeneration and many of the most lethal diseases to which persons
in the latter half of life are liable. Constant high blood-pressure affects
the heart (§ 61).

The administration of digitalis and other cardiac remedies must be
regulated by the condition of the pulse. Thus in cardiac valvular disease
with slow full pulse digitalis should not be given, but only when the pulse
b of low tension, quick or irregular. The prognosb of auricular fibrillation
may be gauged by the extent of the response to digitalis (§ 51). If, on
the other hand, the pulse becomes irregular or too slow during the ad-
ministration of digitalis, the drug should be at once withdrawn.

The supervention of acute inflammation within the abdomen — needing,
perhaps, prompt surgical interference — is indicated by a rapid pulse,
an3rthing over one hundred is my own guide. The supervention of inter-
mittency is a still more urgent sign.

The student should learn by constant and repeated observation what
important lessons can be learned from the pulse.

ARTERIAL DISEASE.

§ 64. Symptomatology. — Among the symptoms to which arterial
disease may give rise are giddiness or ^' dizziness," feelings of faintness,
slight syncopal attacks, headache, paroxysmal dyspnoea, gangrene, or
other conditions referable to the extremities (Chapter XVII.). But
each of these symptoms, excepting the last named, may be caused by
disease of some other physiological system. It is only when several of
them are met with together, and an examination of the heart and arteries
lends confirmation to the idea, that we are led to conclude that the
vascular system is at fault. The importance of arterial disease depends
more upon its effects on the heart, and indirectly on the other organs and
tissues of the body, than upon the vascular condition per «e.

§ 65. Pfaysioal Signs of Disease of the Arteries. — The physical signs
are very few in number, and consist simply of a visible or palpable thick-

SM] ATHEROMA 111

ening, dilatation, or tortuosity of the superficial vessels, such as the
temporals, radials, brachials, and sometimes carotids. There are three
features to note concerning the accessible arteries : (i.) The size of the
artery should be observed as we compress or roll it beneath the fingers—
a feature which sometimes required considerable experience to recognise,
(ii.) The thickness of its wall; and it must not be forgotten that high
arterial tension may produce the sensation of a thick wall, and vice versa.
The thickness of the wall is best ascertained by stopping the pulse with
the fingers of one hand, and rolling the empty tube beyond the under
fingers of the other hand, (iii.) By passing the fingers up and down
the length of the tube, the bead-like thickening due to atheroma may be
detected.

The arteries are much more prone to disease than are the veins, which
is in keeping with the greater liability of disease to attack the left than
the right side of the heart — at least, during extra-uterine life. The Chronic
Diseases of the Arteries which admit of clinical recognition are as follows :

L Atheroma. II. Arterial Sclerosis (synonyms : Arterial Fibrosis, Arterio-
oapillary Fibrosis, etc.). III. Arterial Hypermyotrophy. IV. Functional Disease
of the Arteries (9e'3 Diseases of the Extremities, Chapter XVII.). V. Aneuiysmal
Dilatation. VI. Chronic Endarteritis, due to syphilis and other causes, is only
recogniaed by its pathological effects (cerebral softening, gangrene, etc., see Diseases
of the Nervous System : Anatomy). Acute Endarteritis is generally part of Acute
Endocarditis (§ 39). VII. Embolism, or the blocking of an artery by an embolus,
is the result usually of cardiac disease, especially infective endocarditis ; or it may
be secondary to thrombosis. VIII. Thrombosis, or the coagulation of blood in a living
vessel, is usually the result either of local disease involving the vessel, or of some blood
change. Both this and Embolism are dealt with elsewhere. See, for example.
Localised Dropsy, or Phlebitis (Diseases of the Extremities, Chapter XVII.).

§ 66. Atheroma. — ^Atheroma has unfortunately come to be used in a somewhat
vague sense, but it is taken hero to mean a localised or patchy thickening of the tunica
intima, ooctirring for the most part in patients past middle age, unaccompanied, as
a rale, by any obvious symptoms during life. It starts as a localised hyperplasia in
the deeper (external) layer of the tunica intima ; and the change may go on to a fatty,
caseous, and sometimes calcareous, degeneration. When it is advanced, the middle,
and even the external, coats may be invaded. It is generally more or less wide-
spread, but the disease nearly always commences and predominates in the larger
vessels — ».e., in the aorta and its branches. Consequently, if it be detected in the
radial or temporal, the inference is that its distribution is extensive and that it involves
the vesseb of the brain also.^

Symjitofns are generally altogether wanting.^ However, when the disease involves

^ Some observers say that, with the exception of the coitonary arteries and the
vessels of the brain, it does not usually affect the smaller arteries, but I have satisfied
myself of its existence in the radials and nearly all the arteries of that size in the body
in advanced oases of atheroma.

^ This absence of symptoms has sometimes led me to conjecture whether atheroma
might not be, in a sense, a conservative process, an idea which is further strengthened
by two other important cireumstances — viz., (I) That the change was most constantly
found in those situations exposed to the shock of the systole, as, for instance, on the
upper aspect of the areh of the aorta and in the angle of the bifuroation of arteries.
(2) It was a constant — and therefore, one might say, a physiological — change in
ffreater or less degree in aU elderly people dyins in the Infirmary, no matter what might
be the cause of <&ath. One of the veiy notable cases was that of a woman, aged one
hundred, who died of pneumonia, and who had not at any time presented any cardio-
vascular symptoms during life. |

112 THE PULflE AND ARTERIES t|B7

the ftoita (Mid it nearlj' «lir»yB oomiuenoes in thkt aitualion), it impairs the sUatioitf
of that Btniotiiie, and gives rise to an accentuated second aound of the heart in the
aortio aiea. In the mora advanced oases atheroma maj sometimes be detected ft) a
nodular oi beaded thickening in the ladial, temporal, and other superficial arteriM,
which can be fait by moving the Gngen up and down the artery. The p«tient U.
hovever, unavaro of ita existence, and ma; live to old age, unless he 1m aabjeot to high
tension or other cardio-vasoular disonier.

C(mitquence». — HiBtologioally, the change is almost indijtiaguisfaable from the
■Tphilitjc endarteritia which oocurg in younger persons, and it is only by the >ge of
the patient and tbe history of syphilis that the latter can be diSenmtiBted. Tbore
is, however, a third important difference — viz., whereas syphilitic end»r(«ntw
commonly lesulta in thrombosis, atheroma ntroly does so, unless degenerative changes
occur. Htemorrhage is apt to occur in those cases, due not to the atheroma, but to
thinning and dilatetion of the vessel on the proximal or distAl side. Occurring, as it
does, only in old people, it i« accompanied by, and possibly aids in the production of.
debility and other eigns of old age ; but it is wonderful bow oxtreuely common wide-
spread patchy atheroma is even in
bealthy old people who die of pneu-
monia or some other interourrent
maUdy, e.g., the woman aged one
hundred (see footnote 2, p. 111).

No Ireatnitnt will remove the
atheromatous condition, bat ita
prasenoe is one of the indioatioiu
for the avoidance of the caiUM of
high arterial tension.
Fii.31.— TrNaiLSE)iiLEPci,sE.~w.F.,s«sdfi!ghty- { Q7 Arterial Boleroili.— The t«rm
al(ht. Bbow* ths Bit^top {of virtual untioit, "arterial soleroais" is here used in
UioMniiepuHe. "* wi»iomioal Sense, as a generic

term to mean any widecipread
thickening and hardening of the arterial coala which leads la toss of elMtioity and
contractility of the arteries which is dinwJly recojnuabU. It is too often forgotten
that what may tw called the " parenchyma " of the arterial system — -that is to say,
its functionally active part— is the middle or rauBouUreoat. Upon the proper func
tioning of this coat deijends the whole of the regulator mechanism of the arterial
system, Myexperience»ttbePaddingtonInfirmary,whiob offered a very extensive field
for researches into the pathology of the vagaular syslom. went to show that, although
very wide changesmightBiist in the tunica intimaor tunica adventitia without symp-
toms, very slight changes in the media were nearly always attended by tome kind of
symptom or effect during life. Histologically, therefore, I differentiate intimal, adven-
titial, and medial sclerosiB — the last named bemg by far the most important. ' The
subject of arterial disease is surrounded with conaideiable obscurity, partly because the
same words are used by different observers in very different senses, and partly on account
of the difEoulty of making a sufficiently cihaustive examination of the entire arterial
system in any given cose. A dozen sections of the liver, for instance, will give a fair
idea of a morbid change in that organ ; but to fonn an accurate conception of the
structuial changes in the arterial system in any given case, it may be neoesaary to
carefully examine one or two hundred sections, taken from many different tossbU,
and to make very accurate maumranenU of these, both naked eye and microeoopio.

Symjdonu.-^the clinical courae of the disease may be divided into
two stages : (a) That in which the ventricular hypertrophy is Bufficient
to compensate for the increased peripheral resistance ; and [b) that in
which the left ventricle begins tfl fail— that is, fo yield and dilat*.

(a) In the first stage (1) the patient may be fne fot many years from
any^symptoms referable to the vascular system, so long as tie incaeased
IBM^^" *^™' SolerosU." (TransaoUons of the Pathological Bociety of >London~

iWJ ABTBSIAL 80LEBO8IS 113

peripheral resiBteace ia adequately and not esceBsively compensated
for by the ventricular hypertrophy. SometimeB the patient may come
to m for loBs of vigour or breathleBsneSB ; but more often the thickened

veaaelo are discovered, so to speak, by accident, when the patient cornea

nndet our notice for some other malady. On examination, however, we

may find that the arteries are visibly and palpably thickened at the wrist

and on the temples, being cord-like, and sometimes elongated and

tortuouiB. The feel of the vessel

much resembles that of high

arterial tension (a condition, by

the way, whicli may coezist in

the earlier stages), but by com-
pressing the pulse above and so

emptying the vessel, and then

feeling the artery beyond, the

thickening of the wall may be

readily revealed. By sliding

the fingers up and down, it may

be distinguished from the bead- '

ing of atheroma. (2) As the

disorder progresses, the patient

loses his former vigour, mental

and physical. He is, in a word,

"old before his time," for it

has been truly said a man is

" as old as his arteries." This

loss of vigour is no doubt due

to the fact that all the oigans

and tissues are deprived of that

regulation of nutrition which

depends upon the elasticity and

healthy contractility and re-
laxation of the muscular tissue

of the arteries. (3) Breathless-

nesa, and a tendency to rapidity

of pulse after slight, or even

without, exertion are, in my
experience, the next most con-
stant features. Somerimes the dyspncea is paroxysmal, and the case
resembles asthma. The heart is irritable, and this is evidenced clinically
by breathlessness and a pulse which easily becomes rapid and irregular.
(6) When the second stage is reached, symptoms arise which, as a
whole, form a distinct and well-marked clinical picture. They are due
partly to failure of the arterial functions, but mainly to the failure of
cardiac compensation. In addition to the preceding, which become
emphasised, the symptoms are as follows : (1) Vertigo may have occurred

!1e, 82.— AitebUL SOIBROSIS.— Suction or ■ ladlaL
aiteiy DusaUlad >bOD( 400 dluoeton, ■talmd
vrltb uld OKeIn to (how gnnnlu dagensn-
tloD at moiak flbm in tlu middle coat, wtdcli
conuueuon and pndom^iatat in Ot inltrnal layeri
0/ iRi'ddl* coal. Tbbi niatbod ol pnpantlan brbigs

, _ J Gull and

Sutton maiDtalimd. Tha >pp«uuices dncilbsd
by tbem M uUrlo-capUIanr flbrwls ma »l«aya
be produced by prolonsed httrdanins caapled wKti

Diufficleat staialDg vKh lofwood.

114 THi PVLSi AHfD ARTERIES [ f 67

before the second stage is reached, but the attacks now become more
frequent. Indeed, about nine-tenths of the cases of senile vertigo met
with in the infirmary could be traced to this malady. It is not, however,
a true vertigo, but rather a sensation of " swimming in the head " or
** dizziness," and the patient feels either as if he were " going to fall " or
*' going to faint." So frequently did these attacks occur among tiie
aged and so-called " healthy " old people in the workhouse that they
used to pay but little attention to their frequent falls due to this cause.
(2) Actual fainting attacks are met with less frequently, but when present
they are of more serious import. They vary from a slight interruption
of the continuity of thought on the one hand to a j)rolonged faint or
epileptiform seizure on the other. (3) Physical signs pointing to a varying
degree of h3^rtrophy and dilatation of the heart are revealed on ex-
amination, together with accentuation of the second sound over the
aortic cartilage, if high tension be present. (4) Anginoid attacks, or true
angina pectoris, is another symptom. Quite three-fourths of the cases of
angina pectoris met with in the infirmary were attended by this condition.
(5) In extreme states of the disease, especially when accompanied by
atheroma or endarteritis, there may be gangrene of the extremities, cerebral
softening, either localised or difhise, and similar changes in other viscera.
Miliary aneurysms may arise in the periphery of the arteries of the brain,
and haemorrhage in this situation is one of the most frequent consequences.
There is always in these cases a tendency to the development of low
forms of inflammation, especially *^ senile pneumonia." (6) Renal
fibrosis (chronic Bright's disease) — i.e., granular or gouty kidney — is
very frequently, but not necessarily, associated with arterial sclerosis.
Some hold that chronic Bright's disease is essentially a generalised arterio-
renal disease, and that, although arterial thickening may occur without
renal disease, the latter is always attended by more or less arterial change.

In the Etiology (1) heredity is certainly one of the most important
factors, and families are found in which every member shows a tendency
to this disease on reaching a certain age. (2) As regards age, the disease
is, with rare exceptions, only met with in the latter half of life '} and it
is rather more frequent among men. (3) The pathology of the complaint
is not yet worked out, but in many cases careful inquiry will reveal one
or more of the causes of a constant high tension {q.v.). Various toxic
blood states possibly act in this way, and there is often a history of alcohol,
lead, or gout. (4) Overwork, and physical strain by leading to an over-
filling of the arteries, are also possible causes, on the principle that increased
function causes first increase of structure, and, later, degeneration of the
muscular coat.

Diagnosis. — Arterial sclerosis may have to be diagnosed from (1) high
arterial tension, by stopping the blood current and examining the artery

^ Syphilitic artenal disease is a patchy endarteritis which occurs in younger subjeota
usually more or less localised, and therefore does not come within the scope of our
cpening definition.

} 68 ] ARTERIAL SCLEROSIS 1 15

beyondj (2) atheroma, which gives to the vessel an unequal or beaded
character. (3) Granular kidney, in its slow, insidious onset and vague
symptoms, closely resembles arterial sclerosis in its clinical history, and
can only be distinguished from it by the presence of urinary changes.
The arterial and the renal changes are frequently associated. (4) Other
causes of progressive debility (Chapter XVI.) may have to be distinguished
from arterial sclerosis.

Prognosis. — In the first stage, though nothing can be done to abolish
the thickening of the arterial walls, much may be done to prevent its
advance, and if the patient escape pneumonia and other inflammatory
conditions to which he is liable, he may live many years. The whole
question of prognosis turns very largely on the state of the heart. If
the breathlessness is considerable, and the physical signs show marked
cardiac dilatation, and the pulse is irregular and rapid, the patient is
not likely to live more than a year or two. If, on the other hand, cardiac
compensation is good and the patient feels but little distress on movement,
then the outlook is not unfavourable.

TreatmefU. — The indications for treatment are (a) to keep down the
blood-pressure ; {b) to aid the heart ; and (c) to avoid any extra strain
being thrown upon the heart or vessels. (1) Hygienic measures are of
great value, and the patient's duration of life will depend upon the kind
of existence he can afford to live. He should live a very regular life, free
from any strain on mind or body. The diet should be strictly moderate,
especially as regards proteids, and should be readily digestible. Unless
heart failure is very pronounced, alcohol should be avoided. The
calcium salts in the blood are said to be eliminated by sodium bicarbonate
(2^ drachms) neutralised with lactic acid, 6 ounces of water are added to
this, and it is taken in twenty-four hours. At any rate, this relieves many
of the symptoms of cardiac dilatation. (2) The heart needs our special
attention, and cardiac tonics and other remedies may be administered
on general lines (see Cardiac Failure, § 51). The question of Schott baths
and passive exercises is a most important one, and while some advocate
them strongly, others say that they are attended with considerable danger
by increasing the tendency to haemorrhage and the other consequences
above referred to ; but, in my belief, if the arterial disease is not very
advanced, the heart undoubtedly derives considerable benefit by this
treatment.

§ 98, Arterial Hypermyotrophy is a term which has been employed by the author
to imply a generalised increase in the muscular tissue of the arteries. In a paper
read before the British Medical Association at Bournemouth, in 1891,^ based upon
a collection of cases which were observed in the Paddington Infirmary, it was shown
that a generalised increase in the muscular tissue of the arteries occurred as a distinct
clinical and pathological entity, consequent, in all probability, on states of prolonged
or frequently recurring high tension, by the simple physiological law that increased

^ Cases of arterial hypermyotiophy and the resulting degenerations in the muscular
tissue were published in the BriUsh Medical Journal, January 23, 1897, and the Trans-
actions of the Pathological Society of London, 1904.

116 ^ THE PULSE AND ARTERIES [ f

function leads to increaaed structure. In 1895 Drs. Dickinson and Eolleston ^ showed
that a widespread increase of the muscular tissue of the arteries occurs throughout
the body in some cases of renal disease. Sir Clifford Allbutt^ has described under
the name Hyporpiesis (constant high blood-pressure and its attendant symptoms),
a condition which, from a clinical standpoint (for none of the cases were confirmed
by autopsy), probably corresponds with the condition which the writer, from an
anatomo-clinical standpoint, has called ** arterial hypermyo trophy."

Tho change itself consists of a hypertrophy of the middle or muscular coat of the
arterial walL It affects principally the medium and small-sized arteries of the body
— those which normally contain more of this tissue than is found in the laiger vessels.
Patients may exhibit no sjrmptoms, and rarely die in the early stages of the disease
or until some granular or other degeneration has taken place in the hypertrophied
tunica media. The condition, however, is by no means an infrequent one, to judge
from tho records of the Paddington Infirmaiy, and if it were not such a laborious task
to examine the arteries of the body, more cases would doubtless be revealed. ^

Symptoms, — (1) The arteries have a thickened but elastic feel, although they may
be of normal size. In a few cases the author has been able to confirm this by means
of Oliver^B arteriometer. The prolonged first stage is always accompanied sooner or
later by cardiac hypertrophy. It may exist unknown to the patient for many years,
and be overlooked by the doctor, or, like arterial sclerosis, discovered accidentally.
Sooner or later, however, one or more of these symptoms arise, viz., (2) postural
vertigo from loss of arterial adaptability to posture ; (3) dyspnoea (sometimes of an
asthmatic or paroxsymal character) ; (4) persistent or recurrent headache ; and
(5) symptoms of high arterial tension. (6) In the second stage of the disease, when
granular degeneration and consequent rigidity are present, the symptoms are in-
distinguishable from those of arterial sclerosis, which, in point of fact, supervenes.
It is more often found in persons over forty.

Effects. — Tho results of the thickening in the first stage are (i.) a diminution of
the lumen of the vessels by reason of the tonic spasm ; (ii.) a more or less permanent
increase of arterial tension (blood-pressure); {iu.) pari peissu with the arterial thicken-
ing and high tension there is hypertrophy of the left ventricle. As the result of the
insufficient or ill-regulated blood-supply, the tissues are insufficiently nourished,
and tend to degenerate, and are more readily prone to inflammation and disease.
Tho patient loses his mental and bodily vigour. In the second stage cardiac compensa-
tion faib. and the middle coat of the arteries degenerates — the consequences of which
are identical with arterial sclerosis above described. Arterial hypermyotrophy is
no doubt often associated with granular kidney, probably in about haj^ the oases.
But from the cases which the author has collected, it is evident that arterial hyper-
myotrophy may occur quite independently of renal disease of any kind.

The Prognosis of the condition in its early stage is favourable, if the patient can
live a careful life, although its existence adds to the gravity of intercurrent diseases.

The Treatment in the early stage is that of high arterial tension (§ 61) ; in the later
stages that of arterial sclerosis (§ 67). Symptomatic treatment is always useful.
For tho breathlessness, nux vomica and digitalis, and aperients, especially I or 2 grains
of calomel, are at all times useful. For the attacks, especially the vertiginous attacks,

^ See the Lancet, 1895, vol. ii., p. 137.

3 The Lane Lectures, Philadelphia Medical Journal, April, 1900, pp. 400-500 ; and
elsewhere (e.g,, "" The Hunterian Oration,'* c 1885).

^ It has been said in criticism of these observations that the change consists of a
swelling of the individual muscular fibres rather than a numerical increase. This is
difficult to refute, because the opportunity does not often occur of examining the
arteries before the granular swelling — which is also a consequence of the same cause
(high tension) — has also occurred. But, in the first place, I would point to the actual
occurrence of true h3rpertrophy in renal cases, as shown by Rolleston and Dickinson.
Secondly, I have occasionally been fortunate enough to secure cases — dyine by
accident, for example — which undoubtedly exhibited a true hypertrophy wiUiont
degeneration. Thirdly, a very careful examination of several of my oases shows that
there was an actual increase in the unstriped fibres, in addition to tneir degeneration ;
and, fourthly. Sir Clifford Allbutt's clinical observations undoubtedly lend confirma-
tion to the existence of such a pathological condition as arterial hypermyotrophy.

§»] ARTERIAL HYPERMYOTROPHY 117

nothing gives bo much relief as nitioglyoerine, and for the severe ones oooasionai
inhalations of amyl nitrite. This is an undoubted fact, and constitutes one of the
reasons in support of the theory tiiat these seizures are of entirely circulatory origin.
It also supports the idea that it is muscular spasm, and not the degenerated arterial
wall, which produces the vertigo. For the fainting attacks, alcohol is indicated in
small doses, but I have found that alcohol in anything but very Amall quantities
aggravates the symptoms and consequences of the disorder.

f 69. Fnnetional DiseMes of the Arteries. — Of functional diseases or vaso-motor
derangements we know but little, although several very important maladies are
attributed to this cause — €.g., Raynaud's disease and migraine. Functional derange-
ment of the arteries is also manifested by a large number of S3rmptoms; many of which
are vague and evident only to the patient. On this account they are apt to be
regarded by medical men as unimportant, and it is true tiiat they are not serious in
the sense of being letiial ; but to the patient they are often extremely disagreeable,
irksome, and often terrifying. Of such we may mention alternate flushing and
palk>r (" flush-storms *'), dead hands, cold hands and feet, chilblains, various other
erythematous conditions, blue nose, palpitation, tachycardia (f 40), paroxsysms
of copious urination, acropanesthesia, erythromelalgia, feelings of suffocation, pseudo
and true angina pectoris, feelings of tingling, itchi^. throbbing, and actual swelling
of the limbs. A case of the last named is referred to under the heading (Edema
(§ 425).

Aneuryiinal Dilatation of the Arteries belongs to surgeiy. excepting aneurysm of
the thoracic aorta (see f 53). the abdominal aorta (§ 188), and the cerebral arteries
(CSiapter XIX.). BmboUsm and Thromboeit are referred to under Diseases of the
Extremities (Chapter XVII.) and the Brain (Chapter XIX. ).

1*« THE PULSE AND ARTERIES

function 1^ to increaaed structure. In 18ft5 Dre. Diokmson and 1\< , i
th»t a widc«prMd mciMae of the muscmJar tissoe of the arteries n. .
the body in eome caees of lenal disease. Sir Cliffoid AUbutts has d
the naine Hypoipieos (constant high blood-pressure and it« attenda
a condition which from a clinical standpomt (for none of the caM- •
by •utopey). pioUbly eoneeponds with the condign which the u
anatoimM^lmical standpoint, has ^lled " arterial hypennyotit,phv.

The change it«oif consists of a hypertrophy of the middle or unisc
ertonal waU. It afifects principaUy the medium and smaU-sized art.

--tho» which noimaUy contain more of this tissue than is found iu t
Pfctiente may exhibit no symptoms, and rarely die in the early Bta^.
or untU some gmnuUr or other degeneration has taken place in li
tumca media. The condition, however, is by no means an infrvuu,
ffom the «conis of the BMidington InfirmaTy. and if it were not .u. 1.
to examine the artenes of the body, more cases wouW doubtless hv n

bympamt — (1) The arteries have a thickened but elastic feel a]
be of noiinal siic. lii a few cases the author has been able to contim. •
of Ohver 8 artenometer. The prolonged first stage is always accon
later by caidiac hypertrophy. It may exist unknown to the patio, f^
^ be overlooked by the doctor, or. hke arterial adeiosis. discover,. <
Sooner or Uter, however, one or more of these symptoms ari«e ..
mfvo frem bss of arterial adaptalrility to posture ; (3) dyspnc^n'
uthmatic or pa«)«ymal character); (4) persistent or 4eunvnt
(5) symptoms of high arterial tension. (6) In the second staire of ti.
gimnular degeneration and consequent rigidity are present the ^
dietmguishable from those of arterial sclerosis, which, in p<iint J'
It is more often found in persons over forty.

i-^ecto—The results of the thickening in the firH stage are .i ,
the lumen of the vessels by reason of the tonic spasm ; (u!) a mci,
mcieaw of arterial tonmon (blood-prcssure); {m,) pari passu with o.
uig ^d high tenaon there is hypertrophy of the left ventricle. A.
msuffici^t or lU-reguUted blood-supply, fh^ tissues are in^u]'

The patient loef« his mental and bodily vigour. In Oie *eco«rf staiz.
tion fails, and the middle coat of the arteries degenerates— the o<
are identical with arterial sclerosis above described. Arterial
no doubt often associated with granular kidney, probably in
But from tile cases which the author has collected, it is evident
iD>-otrophy may occur quite independently of renal disease of <n^
The ProgfUisu of the condition in its eariy stage is favoi,,'. ' '
live a careful hfe. although its existence adds to the gravity of
The Treatment in the early stage is that of high arterial tin^i
stages that of arterial sclerosis (f 67). Symptomatic trca*
For the breathlessness. nux vomica and digitalis, and aperin t^
of calomel, are at all times useful ^or^ attacks. especiaJ i
» See the LancH, 18»5, vol. ii, p. 137.
a The Lane Lectures. PhUadelpkia Medical Journal A , -,
elsewhere (e.g„ ** The Hunterian Orataon." c 1886) '

» It has been said in ori^ism of these obeervatious tli^
Bwelling of the individual muscular fibres rather than •
difficult to refute, because the opportunity does not If"
arteries before the granular sw6llmfl---whioh is also a < .

(high tension)— has also occurred. Bol^ a tiM fiist p5 .
occurrence of true hypertrophy m tmml mmm^ wmaho.l
ijeoondly. I have oocasioiial^ hmm talmHlt en< .,

con-.

t*.

iJNlOfi

accident, for example— whM «il49^Mli|RcJMJUbit
degeneration. Thiiditj. a ^^*>QF JMBI^BK^n
there was an actual Jniiiwai
and. fourthly. & O
tion to the exirtnwt «Ei

119

that recurring wheezy cough,

' tuchitis. I ]

vomiting occur in whooping-

^^9 is attended by paroxysmal

iN HO also is the rupture of an
jh, with or without expeotora

' tads and other mediastinal

uons is very characteristic, and

' occurs in nervous and hysterical

five disorders, where there is

, and with chronic liver disease.

L in the early morning and on

^h early phthisis. There may or

/ innda. When a patient com-

1 lying down, the uvula should

••' of congestion will cause con-

t it will irritate the back of the

M assumed. A night cough is

'is in children.

h^of hysteria is very character-

>n.

>ciated with pleurisy or pleuro-

diagnostic; in the former it is

)ciated with aneurysm and other
11 once heard is readily recognised.
tion in the area of the pneumo-
^tinal disorders, such as dyspepsia,
Iren ; (ii.) pericarditis ; (iii.) carious
})acted wax ; (v.) abdominal disease
•hragm — e,g., by subphrenic or liver

•f cough is somewhat important in

1 may be met with, affections other

ort dry cough is set up by going into

•il congestion or irritation. In simple

1 in paroxysms, especially after talking.

ii comes on in a warm atmosphere, we

11 ic irritation of the larynx or trachea

morning, when a paroxysm is induced

i-". glairy mucus. The face is congested,

. vomiting.

iids upon the cause, but, in general terms,
lied by bromides, minute doses of opium,

CHAPTER VI

THE LUNGS AND PLEURiE

Owing to the extreme vascularity of the lungs, it is not surprising that
inflammation of these organs is a frequent complication of acute general
or blood diseases. Thus, inflammation of the lungs is one of the commonest
accompaniments of the acute specific fevers and other microbic disorders.
Again, in the generalised blood infection which arises from a local tuber-
culous focus, the lungs are, as we should expect, frequently the seat
of tuberculous lesions, and there are three actUe forms of tuber-
losis in which the lungs are more or less involved — namely, a
tuberculous form of Acute Pneumonia (§ 87a), Acute Miliary (generalised)
Tuberculosis (§ dSla), and Acute Pulmonary Tuberculosis (§ 83). All the
blood of the body is oxygenated in its passage through the lungs, and the
lungs are in consequence the great defensive organs of the body. Close,
heated rooms with tainted air not only prevent the lungs from duly
performing their defensive function, and hence decrease the power of the
blood to cope with disease, but they are also the means of conveying
disease to the lungs themselves. Chronic pulmonary tuberculosis (phthisis),
one of the scourges of civilisation, is due to the inhalation of air containing
tubercle bacilli. Both for the protection of the lungs themselves and of
the entire organism which demands a pure blood-supply, the importance
of the gospel of fresh air cannot be overrated.

PART A, STMPTOMATOLOar.

The Cardinal Symptoms of diseases of the lungs are oongh, lireath-
lessnesf , expectoration, and sometimes iMun in the chest and h»moptyiifl.

The more general symptoms are pyrexia, emaciation, and debility. The
heart, more especially the right side, suffers sooner or later in all serious
or prolonged pulmonary diseases by interference with the pulmonary
circulation.

§ 70. Concerning Cough, if it is attended by expectoration (as in 1 to
4 below), it points to definite changes either in the lungs or throat. If
without expectoration (as in 5 to 8 below), it may point to simple con-
gestion of the throat or larynx, to the presence of pleurby, to the early
8ta^e of some pulmonary disorder, or to some source of reflex irritation.
The Causes of Cotigh are as follows :

118

§70] OOUQH 119

1. The commonest form of cough is that recurring wheezy cough,
attended by expectoration, 8o^t3rpical of bronchitis. i ]

2. Paboxtsms of coughingTfollowed by vomiting occur in whooping-
cough and advanced phthisis. Bronchiectasis is attended by paroxysmal
cough with foetid expectoration at intervals, so also is the rupture of an
empyema into a bronchus. Paroxysmal cough, with or without expeotora
tion, occurs with enlarged bronchial glands and other mediastinal
tumours.

3. The HAWKING cough of throat affections is very characteristic, and
is met with in catarrhal pAaiyn^^i^. It also occurs in nervous and hysterical
subjects. It is also associated with digestive disorders, where there is
often a collection of mucus in the pharynx, and with chronic liver disease.

4. The iRRrrABLB cough, most marked in the early morning and on
going to bed, is especially associated with early phthisis. There may or
may not be much expectoration.

5. A NIGHT cough may be due to a long uvula. When a patient com-
plains that a cough is worse at night or on lying down, the uvula should
be carefully examined. A slight degree of congestion will cause con-
siderable elongation of the uvula, so that it will irritate the back of the
phamyx when the recumbent posture is assumed. A night cough is
also associated sometimes with threadworms in children.

6. The long barking or nervous cough^of hysteria is very character-
istic. It is unattended with expectoration.

7. The SHORT SUPPRESSED cough associated with pleurisy or pleuro-
pneumonia is so characteristic as to be diagnostic; in the former it is
unattended by expectoration.

8. The GANDER or brasst cough associated with aneurysm and other
mediastinal tumours is typical, and when once heard is readily recognised.

9. The REFLEX cough, due to irritation in the area of the pneumo-
gastric, may be caused by (i.) gastro-intestinal disorders, such as dyspepsia,
constipation, diarrhoea, or worms in children ; (ii.) pericarditis ; (iii.) carious
teeth ; and (iv.) ear troubles, such as impacted wax ; (v.) abdominal disease
in which there is irritation of the diaphragm — e,g,y by subphrenic or liver
abscess.

The Diagnosis of these varieties of cough is somewhat important in
practice, since they arise from, and may be met with, affections other
than those of the lungs. When a short dry cough is set up by going into
the cold, it may be due to phar3n[igeal congestion or irritation. In simple
throat affections the cough comes on in paroxysms, especially after talking.
On the other hand, if such a cough comes on in a warm atmosphere, we
should suspect phthisis. In chronic irritation of the larynx or trachea
the cough is worst in the early morning, when a paroxysm is induced
by the effort to bring up a little glairy mucus. The face is congested,
there is difficult inspiration, even vomiting.

The Treatment of cough depends upon the cause, but, in general terms,
irritable coughs may be soothed by bromides, minute doses of opium,

120 THE LUN08 AND PLEURA [ §§ 71, 72

heroin (yV to } gr.), by a linctufl of squills and tolu, or by various medicated
lozenges, such as the B.P. morphia and ipecacuanha and krameria lozenges.
§ 71. Breafhlessness, or dyspnoea, is another symptom of lung alEec-
tions. The causes of breathlessness are dealt with in more detail in the
symptomatology of cardiac disorders (§ 20). The types of breathlessness
special to respiratory disorders are :

1. Breathlessness attended by sniffino and nasal bubbling is caused
by nasal or naao-pharyngeal catarrh. The obstruction in the nose or
mouth usual in such a condition may also cause considerable stertor at
night-time.

2. Stbidxtlous respiration, in which the stridor attends both inspira-
tion and expiration, is caused by obstruction in, or pressure upon, the
trachea or larynx. It is accompanied in severe cases by drawing in of
the epigastrium and lower costal cartilages during inspiration (§§ 1226, 127,
and 128).

3. Dyspnoea attended by considerable whbbzino or rhonchi in the
chest is very characteristic of br<m(A%tis, attended usually by emphysema.

4. The LABOURED respiration which attends other grass diseases of the
lungs is different from any of the foregoing. Under this heading also
comes the expiratory dyspnoea of emphysema, which is due to the fixation
of the chest in a position of inspiration. Undoubtedly the conmionest
lung condition giving rise to dyspnoea is emphysema, which is revealed
by a barrel-shaped chest and h3^r-resonance.

5. A rapid respiration with altered pulse-rbspiration ratio is almost
diagnostic of lobar pneumonia. In children there is seen in this disease
a characteristic working of the alse nasi.

6. Paroxysmal dyspnoea is present in asthmatic attacks, but is more
often an indication of cardiac disorder (§ 20a).

§ 72. Pain in the Oheit is usually present with affections of the pleura, but other-
wise it is not a constant symptom in pulmonary disorders. The various causes of
pain in the chest are enumerated in § 23. The following are the chief types of pain
met with in diseases of the lungs :

(i.) The SHARP, cutting, stitch-like pain of pleurisy, before the effusion separates
the inflamed surfaces, is greatly aggravated by drawing a long breath. This is un>
doubtedly the commonest of the pulmonary causes of pain in the chest, and this
symptom in pneumonia indicates involvement of the pleura. It must be remem-
bered, however, that in some sub-diaphragmatic diseases — e,g., of the liver, spleen, or
colon — pain is also felt on deep inspiration. One of the most intense forms of pain
in the chest is due to diaphragmatic pleurisy. It is referred along the lower costal
margin, and is accompanied by very shallow respirations, which are chiefly or entirely
thoracic. Hiccough is occasionally associated. (iL) A sorbnbss behind the upper
part of the sternum attends the onset of acule bronchitis, (iii.) Sxtdden severe pain,
followed by considerable pulmonary and general distress, occurs with the onset of
pneumoUiorax. (iv.) Suddkn pain, attended by hasmoptysis, marks the occurrence
of embolism of the lung or rupture of an aneurysm into the lung, (v.) Cancer of the
lung may or may not be accompanied by pain, according to its proximity to the
pleura or other sensitive structures, (vi.) All mediastinal tumours give rise sooner
or later to pain in the cheat.

The presence of expactoration or sputum is an important sign ; its
physical appearance may lead to the diagnosis of certain lung diseases.

§78] CAUSES OF HEMOPTYSIS 121

It must be examined by the physician, and it is therefore described in
§ 78. It must be remembered that children usually swallow sputum ;
so also adults with bad habits or unconsciousness. Expectoration from
the pharynx must not he mistaken for expectoration from the bronchi or
lungs. The amount of coughing rerfuired to void the sputum may aid
diagnosis — e.^., in the early stages of bronchitis much coughing brings up
a little tenacious sputum, in the later stages moderate coughing brings up
much forthy muco-purulent sputum.

§ 78. Haemoptysis means the spitting of blood (affia, blood ; irnV),
to spit), but the term is confined to the expectoration of blood from the
organs of respiration.

T\i& fallacies with regard to this symptom are very important, and it
is sometimes as difficult as it is important to decide whether the blood
comes frofti the throat or nose, from the stomach, or from the limgs. The
differentiation is given more fully under Haematemesis (§ 192), but it may
be mentioned here that blood coming from the lungs is thus characterised :
(i.) It is preceded and accompanied by a tickling cough (if the blood be
large in quantity it may excite retching on toucUng the pharynx) ;
(ii.) the patient usually goes on coughing up a little blood for some time
afterwards ; (iii.) the blood has a bright red colour, is alkaline, and frothy
(if very profuse, it may be dark in colour and without froth) ; (iv.) physical
signs of disease of the lungs are usually, though not always, present —
they may be absent in the early haemoptysis of phthisis ; (v.) the ante-
cedent history of the patient may point to pulmonary tuberculosis or to
cardiac disease, these being undoubtedly the most conmion causes of
haemoptysis.

Causes, — For practical purposes the causes of haemoptysis may be •
divided into two groups :

(a) Those which produce slight and sometimes protracted or recurrent
bleeding ; and (b) those which produce a copious bleeding at one time.

(a) Causes of Slight and Sometimes Protracted Hcemoptysis, — I. Phthisis
is by far the commonest cause. The haemoptysis of phthisis may occur
either in the early or in the advanced stage of the disease, and in either
case it may be small or very large in amount. The presence of this cause
may be recognised (i.) by the previous and family history of the patient ;
and (ii.) by evidences of congestion, consolidation or cavitation of the
lung (§ 77). Nevertheless, the most careful examination may fail to reveal
any signs, because haemoptysis is frequently the earliest symptom of
invasion by the tubercle bacillus.

II. Cardiac Disease, especially mitral stenosis or the late stage of
mitral regurgitation, is the next most common cause of haemoptysis.
It may arise in such cases either from congestion, or, more rarely, embolism
of the lungs. In both cases evidences of cardiac disease are present.

in. Various Pulmonary Diseases other than phthisis may be attended
by slight haemoptysis. Thus, in a^mte bronchitis the sputum may contain
streaks of blood from time to time ; and in pneumonia the sputum is rust-

122 THE LUNGS AND PLEURJB [ f 7Sa

coloured about the third or fourth day of the illness. In chronic bron-
chitis with emphysema the sputum may at times be blood-streaked. The
haemoptysis due to carcinoma of the lung may be recognised by the irregu-
larity of the physical signs. Abscess and hydatid may cause bleeding.

IV. Ulobration of the upper part of the respiratory passages may
give rise to haemoptysis, small in amount, and apt to be recurrent. A
careful examination of the throat and larynx generally reveals this cause.

V. VioARioirs Mekstbitation as a cause of hsBmoptysis is disputed by some. It
is recognised by ite oocnrrence at the time when menstruation is due, the normal
menstrual function being absent, and by the absence of signs of disease in the
lungs.

VI. GoKSTiTUTiONAL or idiopathic causes. There are certain patients in whom
slight hsemoptjrsis occurs from time to time, the history and examination revealing
nothing, and the patient living to a good old age. The haemoptysis in such cases is
explicable by two hypotheses — ^the presence of undiscoverable tuberculosis, or a
transient congestion due to some constitutional cause. Thus Sir Aitdrew Clark
found •hffimoptysis in subjects of the arthritic diathesis. It occurs in subjects of
arterial and renal disease.

§ 78a. Pulmonary Embolism complicates mitral disease, septic venous throm-
bosis, and other conditions in which there is intra-vitam clotting in the vessels. Small
emboli may give rise to few clinical signs, the chief being pain in the chest, sudden
dyspncsa and hsBmoptysis. The appropriate treatment is the administration of cardiac
and general stimulus — e,g., strychnkie, digitalis, ether.

When large thrombi are dislodged from distant parts and travel to the lung, the
patient dies at the moment of their impaction in the pulmonary arteries. There are
no premonitory symptoms ; even the existence of a clot may be unsuspected. Suoh
clots are not uncommonly found to have originated in the pelvic veins. Cases of
sudden !death following operations when the patient appeared to be in excellent con-
dition are usually due to this variety of thrombosis. For these cases there lb no
treatment except a watchful care lest patients are allowed to get up too soon after
operations.

(b) Causes of Hcemoptysis in which there is a Considerable Quantity of
Blood at One Time — ^I. Phthisis. — Copious bleeding (which may be con-
tinuous, perhaps for hours or for a day or two), without ending fatally,
is almost invariably due to pulmonary tuberculosis. The chief features
by which it is recognised are given above.

II. Rupture of an Aneurysm into the trachea or bronchus is a by no
means rare accident in the history of that malady. It is the one cause
of haemoptysis which is usually followed by immediate death, though
in some cases there may be a considerable leakage going on for a day or
two before the final issue (§ 53).

III. Ulceration of the larynx, throat, trachea, though usually causing
small and recurrent haBmorrhages, occasionally leads to a large amount
of hsBmorrhage.

IV. Purpura, hsemophilia, scurvy, leucocythaemia, and some other
Blood CoNDmoNS may be attended by bleeding from the lungs. These
causes are for the most part rare, but when present are readily recognised.
It may also occur with the eruptive fevers.

Differentiation. — In order to arrive at a diagnosis of the cause of
haemoptysis in any given case, we must first of all examine the chest
(lungs and heart) very thoroughly; secondly, use the laryngoscope to

§ 74 ] PULMONARY EMBOUSM 123

investigate the larynx and naso-pharyngeal passages; and, thirdly, we
most inqniie into the patient's history.

* The Prognosis depends, of course, upon the cause. Hsemoptysis is
nearly always a serious symptom, and when profuse is followed by con-
siderable debility. In this way it may hasten the end of an advanced
case of phthisis. But the h8Bmopt3rsi3 of early phthisis, though indicating
definite involvement of the lung tissue, is not so serious, and with
proper precautions the patient may completely recover and live to
old age.

Treatment, — (a) For projuae hcBmorrhage immediate treatment is
necessary. The patient must be kept at absolute rest in bed. Ice is
usually applied to the chest, but it should not be kept on in one place
longer than twenty minutes at a time. The nourishment allowed must
be cold. A hypodermic injection of morphine (gr. ^), or full doses of
opium with acid, sulph. dil., or turpentine internally (T1\^xxz. in mucilage
four-hourly, and gradually reduced), are the most efficacious remedial
drugs for early administration. Ac. sulph. dil. (T\x.) with alum (gr. v.)
may then be given every twenty minutes. A large dose of ergotin succeeds
in some cases. Whitla recommends turpentine vapour in the room.
Other drugs recommended are amyl nitrite, which dilates the arteries and
so relieves the veins and capillaries, gallic acid, hazeline,^or atropin or
digitalis hypodermically. Full doses of ipecacuanha or other emetics
have also been reconmiended.

(6) When hsBmoptysis occurs in small ^pMntity, calcium chloride (g. xx.
every four hours) renders the blood more coagulable, and is specially useful.
The hssmorrhage of congestion due to cardiac disease should not be checked,
unless it becomes excessive, as it relieves the pulmonary congestion.
When hssmoptysis occurs in elderly arthritics, give a sedative cough
mixture, saline purgatives, iodides, and cod-liver oil.

PART B. PHT8I0AL EXAMINATION.

The physical examination of the lungs is carried out by means of
Inspection and Mensuration, Palpation, Percussion, and Auscultation.

§ 74. biqieotion and HensoratioiL— The inspection of the chest must
be carried out in a good light, and the patient must be instructed to
stand or sit erect, or, if in bed, to lie flat and evenly, and to breathe deeply.
After noting the movements from the front, examine the back, then look
from behind over the clavicles in order to make out the slighter distor-
tions or inequalities of the chest. By inspection and mensuration we note
(1) the rate and character of the breathing ; (2) the shape and size of the
chest ; (3) the chest capacity. The chief landmarks of the chest are
mentioned in § 31, and the regions into which, for descriptive purposes,
it is divided anteriorly, are given in Fig. 33. Posteriorly the chest is
divided into the suprascapular, scapular, and infrascapular. The
scapular region is divided, by the scapular spine, into the infra- and supra-

12* TBB LVSaS AND PLEVBS { % 74

BpinouB regions. The names sufficientlj indicate the positions of the
various regions.

1. Bate and Charade of the Breaiking. — The rate Taries normally from
1*1 to 20 per minute, or onp-fonrth the rale of the pulse ; and any diange
in this proportion, or pulse- respiration ratio, should be observed. Notice
whether the breathing is rapid, slow, shallov, or irr^fular. The respira-
tion should be counted without the patient's knowledge ; thus while
counting the breathing, it is a good plan to feel the radial artery as if you
were examining the pulse. Both sides should move equally. Flattening
or immobility of any part of the chest points to disuse of that part of the
lung — e.g., from consolidation. Flattening or protrusion of the inter-

ns, »:),— Anleilflr Thotacln Ragionii.

spaces indicates fluid. Drawing in of the interspaces on both sides during
inspiration is indicative of some interference with the free entry of air into
the lungs (inspiratory dyspnoea), as in diphtheria or other cause of obstruc-
tion of the larynx or trachea. Ckeyne-Stokeg breathing is a peculiar
rhythmical irregularity of breathing (see § 20b). When movement of the
chest causes pain, as in pleurisy, or when the muscles of the chest wall are
paralysed, there is abdominal breathing.

2. The Shape and Size of the Gheet.—k cross-section of the heaUhy adult
chest gives almost the form of an ellipse, the longer diameter being from
side to side. In the child it is more circular in shape. The chest should
appear symmetrical, although la reality the right side is slightly larger

174]

INSPECTION AND MENSURATION

125

than the left. There should be no marked hollowing anywhere ; the
clavicle should form only a moderate prominence between the supra- and
infra-clavicular regions. The circumference of the chest varies with the
height of the individual, but it should average for a man 5 feet 6 inches
about 34 to 35 inches. With deep inspiration it should expand about
1^ to 2 inches. The measurement at the level of the nipples in the male
is a rough measure of the individual chest capacity (see above). The
relative shape and capacity of the two sides is measured by a cyrtometer
(see also p. 126). The principal abnormalities in shape are the emphyse-
matous, phthisical, and rachitic chests.

The commonest form of abnormality in the shape of the adult chest is
the emphysemaUms, or, as it is called, the barrel-shaped chest. Briefly
expressed, this alteration consists of the fixation of the chest in a position
of permanent inspiration, and expiration cannot be completely performed.
The sternum becomes curved, the low^r
part being unduly drawn in; and a
horizontal section shows the chest to
be unduly circular (Fig. 34). When
the hands are placed flat upon the
chest on each side, they readily ap-
preciate the fact that in advanced
cases there is elevation, but no lateral
expansion of the thorax, during in-
spiration. The upper ribs are crowded
together, whilst the lower ribs are
farther apart than normal, and the
epigastric angle is very wide. Owing
to the permanent elevation of the

clavicles and upper part of the chest, and the unusual degree of develop-
ment of the accessory muscles of inspiration, the neck looks abnormally
short in an emphysematous subject.

The 'phthisical chest is too long vertically, and, in section, too rounded.
On inspection from the front it appears flat, but this flatness is more
apparent than real, owing to the slipping forward of the scapulae towards
the front of the rounded chest. In the phthisical chest the antero-posterior
is larger than the transverse diameter, as in childhood.

The rachitic chest is common in children. Owing to the weakness of
the bones, the chest acquires a characteristic shape (Fig. 35). A vertical
groove occurs at the weakest part of the wall of the chest — i.e., down each
side of the sternum, just outside the " rickety rosary " or beaded junction
of ribs and cartilages (§ 447). Harrison's sulcus is often present at the
same time ; it is a horizontal groove at the level of the xiphoid cartilage,
running from the middle line in front obliquely outwards and slightly
downwards as far as the mid-axilla, along the costal arch.

The pigeon-breast is found in those who have had some obstruction to
respiration in early youth, such as that due to adenoids or whooping-cough.

Fig. 84. — CH18T OF EMPHTSaXA. The

dotted line represents the normal outline.

126

THE LUNQ8 AND PLEURA

[§76

llg. 86.— Raobitic Chest. The
dotted line represents the
normal outline.

The sternum is prominent, the ribs meeting it at a more or less acute angle.

The cross-section of the chest is therefore almost triangular (Fig. 36).
Among the irregular or asymmetrical abnormalities in the shape of the

chest which the student should look for are hcUomng, prominence, or

contraction,

(a) Localised Hdlomng or "flattening" of the infraclavicular region

may indicate phthisis, or any disease rendering the underlying part of lung

useless for respiration.
(P) Undue Prominence on one side of the ribs anteriorly may be due to :

(i.) Scoliosis — i.e., lateral curvature of the spine, the convexity of the chest

being in the opposite direction, (ii.) Intrathoracic tumour, fluid, abscess,

or air (pneumothorax) in the chest, (iii.) If
the cardiac region be prominent, it may be
the result of cardiac disease in early youth,
before the ribs were fully developed, and
possibly an adherent pericardium, (iv.) An
enlarg^ liver or spleen or abdominal tumour
or abscess may also cause a bulging of the
lower ribs on the right and left sides re-
spectively, (v.) Subcutaneous emphysema or
oedema, a localised deposit of fat or other
tumour.

(y) Contraction of an erUire side of the
chest which may be due to : (i.) collapse of a
lung (§ 100) ; (ii.) previous empyema (§ 86) ;
(iii.) chronic interstitial pneumonia and fibroid
phthisis (§§ 97 and 94a).

The Cyrtometer is an instrument consLsting of two
flexible pewter or pure tin bands joined by a hinge
and graduated in inches. It is used to measure the
relative size and shape of the two sides. Plaoe the
hinge exactly opposite the spinous prooesses posteriorly,
and bend the pewter limbs round to the front following
the contour of the chest precisely. The instrument is
then placed on paper, and the outline thus obtained
may be marked by running a pencil round the band.
AVhon possible, the Rontf en rays should be employed to aid the diagnosis of early

tubercle, tumours, and fluid effusions, and for the detection of the position and extent

of movement of the diaphragm.

§ 75. Palpation is the next step in the routine examination of the lungs.
The amount of movement with respiration is estimated better by palpa-
tion than by inspection. This test is important in the diagnosis of consoli-
dation at one apex, and in the detection of fluid, tumour, or other cause
of deficient activity of one lung or part of a lung. By palpation Vocal
Fremitus (V. F.), or the vibration of the voice, can be felt. It is scarcely
appreciable in women or children with high-pitched voices, but is marked
in the adult man. The V. F. is normally greater at the right than at the
left apex. This test is of the greatest value in differentiating solid and

36.— PiQKON Chest. The
dotted line representB the
uormal outUne.

i n ] PALFATWN^PEHOVaaWN 127

fluid. Thus the V. F. is increased where there is consoUdation of the lung,
as in pneumonia or phthisis, whereas it^is diminished or absent when the
lung b separated from the chest wall by fluid, thickened^pleura, tumour,
or air, or when air is not entering the larger bronchi, as in cases of obstruc-
tion of a bronchus. Not only is the V. F. a valuable differential sign, but
its degree of diminution b a useful measure of the amount of fluid present
in cases of pleuritic effusion. In bronchitis the rhonchi can be felt —
rh<mchial Jremitas ; and in pleurisy and pericarditis yHc^ton may be dis-
tinctly felt by the hand. Tenderness due to broken rib, pointing empy-
ema, subcutaneous emphysema, and external tumours are made out by
palpation.

§ 78. PeroiUHdon is, after palpation, the next step in the examination of
the chest. There are two kinds of percussion, immediate and mediate.
In the latter a piece of ivory or wood is placed on the chest, and is struck
by a small hammer, or with the finger. The immediate is the more usual
form of percussion. To elicit the normal resonance of the lungs percussion
should be stronger than when applied to make out the cardiac dulness.
Begin at the apex and percuss altemate sides at exactly corresponding
points in order to compare the healthy and unhealthy sides, and thus
work gradually downwards. Place the first or second finger firmly and
fiat against the chest, in a horizontal position — i.e., parallel to the suspected
line of dulness. (Only in suspected mediastinal tumour should it be placed
vertically.) Then strike upon it with the tips of all the fingers of the
right hand. The blow should come from the wrist, not the elbow ; and
the " staccato " movement should be imitated. Some use one (the
middle), two, or three of the fingers of the percussing hand, but this makes
Uie stroke too light, unless, as sometimes happens, it is desirable to demon-
strate the delicate shades of pitch, intensity, and quality of the soimd.^

When examining the back of the chest (Fig. 37), the patient should be
instructed to cross his arms and bend a little forward so that the scapulee
are drawn out of the way. The normal resonance of the lung extends
posteriorly to the upper border of the eleventh rib on the right side, and
the lower border of the eleventh rib on the left side. On deep inspiration
the resonance extends an inch lower, and during deep expiration an inch
higher. Owing to the thickness of the scapular muscles the note over
the scapulse may be quite dull in muscular people. To examine the sides of
the chest the patient should be told to put his hands on the top of his head.

The normal pulmonary note can only be learned by practice and ex-
perience, and the student should frequently practise first an normal chests, so
as to accustom himself to the normal resonance ; and afterwards on
abnormal chests.

^ The pitch or tone of the note is its position on the scale, and the more solid the
Btructnie, the higher the note ; the more hollow, the lower and more drum-like or
tympanitic. The intensity of a note depends on the solidity of the wall of a cavity
as compared with its size. The timbre or quality of a note is a characteristic which
depends on the nature and structure of the vibrating body, just as a wire string and a
gut string, though producing the same^oto, possess a different timbre" or quality.

THE LVSOS AND PLEVRJE

The normal pertusaiou note is resonant. It is dvU or flat when the lung
tissue is too solid, as in pDeumooia ; or when the chest contains fluid, as

iduriniupin-
eitenditoUw
Jirib.

Fig. ■iT.—T:B% LUNCS IM) OTBint ViGcUiA FBUM THK ItACR.— The rlglit JuDB Jiu tlireo lubes, tlir
Jclt LuDR tMO only, and Uib lutiClOLi ut ILie Brest lluuree an tboKii in tbe flgiuc. Ibi liDes
on the SsDie are only i[ipiojlinste guiiiei. Whi'n accursc-y ia desired, Ibe exact poilUou
of tbe Inng fiuuiea l> obtained by ansculto-iieraiealon. > rough guide to (he upper border
o( the lover lobea la found in tbe poaiCton of tbe vertebral borden of tbe Acapule wben the
paUeut cToaeea hla anna In front of him, and places each band on the oppoalle abonldei. Tbe
great Ahdic, nbJeh Mparitea Die midiljc and lower lobea, on tbe rlgbt aide, and tbe upper uid
loser loba on tbe left aide, !> Indicated on LoUi gidei by drawlntt a line from tbe tecond donal
vertebra to tbe Junction of the liilb coalal cartilage with (be sternum. The fiuuie leparttlng
tba middle and upper lobca on tbe right aide la found by drawing a line from the Junction
(rf tbe fourth costal cartilage with the atemom to meet tbe line of tbe great Baanre In thg mid-
axUla.

in pleuritic effusion, or with a thickened pleura or turaour. The percussion
note is h^fer-resoHat^, or tympanitic, whenever the lung tissue is unduly

5 77 ] A U8GULTATI0N 129

open — i.e., too full of air, as in emphysema, when there is a cavity near the
surface, or when there is air in the'pleura (pneumothorax). Cracked-pot
aound is a modification due to a large cavity (Phthisis, § 94). It is normal
in children, in whom it is due to the great elasticity of the ribs. When
one part of the lung is over-distended with air, as it is in the part which
is above a pleuritic effusion (which compresses the lower part of the lung),
or above a pneumonic consolidation, the note is unduly resonant. This
kind of resonance is called Skodaic resonance; and it may be almost
tympanitic (drum-like) in character. It is due to the relaxation of the
healthy lung tissue, and the increased amount of air which it contains.

Gairdner's Idne.^ — It is useful to remember that a line diawn from the left anterior
azillaiy fold to the nmbilions is normally resonant thrtmghout its entire length. Abnor-
mally it may be impinged upon anteriorly by oonfiolidation in the upper part of the
loft lung, cardiac enlargement, or by enlargement of the liver ; and posteriorly by con-
solidation or fluid at the base of the lung, splenic enlargement, or other abdominal
tumours.

Increawd Beiistance is another quality which can be observed in the process of per-
cussion as above described. This property of resistance can perhaps be better elicited
by placing a finger of the right hand over an intercostal space and pressing lightly. It
is greatest over fluid, and thus affords an important sign in pleural effusion, but is
present also in consolidation, though in a less degree. It is a sign which, at first, is
difficult to elucidate, but comes to be relied upon, in addition to peroussion, by some,
especially by those whose appreciation of differences in note is imperfect.

§ 77. Auscultation. — In using the single stethoscope, place the small
end flat against the chest, and whUe it is held in this position by the finger
and thumb, adjust the ear to the other end. The tendency of beginners
is to adjust the stethoscope to the ear, but this should be carefully avoided,
else the chest end gets tilted, and the chest sounds are imperfectly conducted.
The ear may be placed directly against the chest, with an intervening towel,
but it does not localise the sounds so well. In auscultation there are
four things to be observed : (a) The character of the respiratory murmur
(R.M.) ; (b) the relative length of inspiration and expiration ; (c) the
presence of adventitious sounds within or outside the lungs ; and {d) the
voice-sounds or vocal resonance (V.R.).

(a) The normal character op the breath sounds — i.e., the vesicular
or " respiratory murmur " (R.M.), caused by the air entering and leaving
the air vesicles, should be listened to in healthy chests as often as possible.
It has a soft whiffing character ; expiration can hardly be heard, but if
heard, there is normally no pause between it and inspiration. The R.M.
is normally very loud in children, and when a loud R.M. is met with in
adtdts, it is called " puerile breathing." The breath sounds are in most
persons harsher over the right apex. The breath sounds are inoreased—
i.e., the breathing is " tubular " or " bronchial "^ when the limg is solid,
as by tubercle, pneumonia, or collapse, or when a new growth lies between

^ It was Sir William Gairdner who emphasised the value of this line in physical
diagnosis, but I am not certain if he was the first to do so.

* The terms " bronchial " and " tubular *' are generally taught as synonymous, but
some schools (e.g., the Edinbureh) teach [that there are three kinds of bronchial
breathing — ^high-pitched, or tubular ; medium-pitched, or true bronchial breathing ;
aad;,low-pitohed, or cavernous breathing.

130 THE LUNGS AND PLEURAE [ § 77

the larger bronchial tubes and the surface. In this condition the sound
produced in the larger bronchi is conveyed direct from them to the ear
owing to the increased conductivity of the solid lung substance. Bronchial
breathing can be heard normally by listening over the upper segment of
the sternum, or near the fourth dorsal vertebra at the back. It has three
features — inspiration and expiration are of equal length and character,
have an interval between them, and are both rough. Cavernous respira-
tion is exaggerated tubular breathing, and is heard when the sound pro-
duced in a dilated bronchus or cavity is conveyed in like manner to the
surface. Cavernous respiration is normally heard over the trachea.
Amphoric breathing is a sound like air entering a bell-jar, and is heard
over pneumothorax or a very large cavity. The breath sounds (R.M.)
are diminished or absent when a layer of fluid, tumour, or a thickened
pleura intervenes between the lung and the chest wall, or when the air does
not enter the lung tissue owing to obstruction in a bronchial tube.

(b) The RELATIVE LENGTH OP INSPIRATION AND EXPIRATION is approxi-
mately as 10 to 12, but heard through the stethoscope, the inspiratory is
three times as long as the expiratory sound, which follows it without a
pause. Expiration is prolonged in any disease which involves a loss of
elasticity of the lung tissue, such as emphysema, or tubercle in an early
stage.

(c) The presence or absence of adventitious sounds has next to be
noted, (i.) Pleuritic friction is produced by the two inflamed and rough-
ened surfaces of the pleura rubbing together, (ii.) Within the lung various
moist and dry sounds may be added to the respiratory murmur. Thus the
presence of excessive mucus or other fluid in the large bronchial tubes
gives rise to "large or bubbling rdles^^ as the air bubbles through the
fluid. When the small tubes or air cells are similarly affected, " small
mucous r&les " or " crepitations " are heard which resemble the rustling
of tissue-paper or hairs rubbed together near the ear. They are audible
in cases of early pneumonia and oedema of the lungs. If the lining mem-
brane of the large bronchial tubes be thickened and dry, or with only a
small quantity of moisture present, " sonorous rhonchi " are produced, like
the snoring of a person asleep. If the smaller tubes are thickened " sibilant
or whistling rhonchi " are heard (see Fig. 40). Rhonchi are often hard to
distinguish from friction sounds, but it may be remembered that, whereas
friction sounds heard during inspiration and expiration are separated by
a short but distinct interval of silence, rhonchi are not so separated, but
fade one into the other. Crepitations sometimes resemble friction sounds,
but are distinguished by being audible only during inspiration.

(d) The voice SOUNDS, or vocal resonance (V.R.). (i.) When the patient
speaks, the vocal resonance is increased {bronchophony) over a cavity, op
if the conductivity of the lung substance is rendered greater by consolida-
tion, such as that produced by tubercle or pneumonia. If this be so great
that even whispered words are conducted, it is known as whispering pec-
toriloquy. Some authors confine this term to the very exaggerated whis-

§77a] . AUaOULTATlON^FALLACIES 131

pering sounds which are heard over large smooth- walled cavities, (ii.) The
vocal resonance is diminished when a layer of fluid or air intervenes
between the lung and the chest wall {e.g,, in pleuritic efEusion and pneumo-
thorax), or when there is a thickened pleura. Nevertheless, in a slight
pleuritic effusion and at the upper level of a moderate efEusion the higher
tones of the voice sounds are sometimes conducted, especially at the angle
of the scapula, and resemble the bleating of a goat (hence called JEgophony),
Clinicalk/, all the diseases of the lungs may be conveniently divided into
those with dnlness on percmudony those in which the percussion note is
normal^ and those in which it is hsrper-resonant Those with dnlness
may be subdivided into two groups — those in which the dulness is due to
CONSOLIDATION, and those in which it is due to fluid. The clinical features
by which solidification of the lung is distinguished from fluid in the chest
are so important that they are given in a tabular form.

Table V.— Physical Signs op

Consolidation of Long. Plenral Effiuion.

'Movement impaired. . . Movement impaired.

InsPEcnoN. . . - May be flattening over the part May be bulging (of intercostal

(if infraclavicular region). spaces).

Palpation. . . V.F. inobeased. . . V.F. diminished or absent.

Percussion. . . Resonance impaired. . . Absolutely dull over fluid.

j BRBAXmNO TUBULAR. . . R.M. ABSENT Or WEAK.

I y.R. INCREASED. .. V.R. DIMINISHED.

(The most important features are in small capitals.)

Auscultation.

AoBcalto-Peronssion, when employed by experienced observers, enables them to
define the boundaries of the heart, or of a mediastinal tumour, with greater accuracy.
It is useful to determine the lobe in which disease is situated. In this method the
stethoscope (preferably, a binaural) is placed over the middle of a lobe, while one coin
is tapped on another, first over another lobe, and then over the same lobe as that to
which the stethoscope is applied. The listening ear recognises the difference of the
impact in the two cases. The coins are then placed over the supposed margins of the
lobes, and by the slighter or stronger impact conveyed to the ear the division between
the lobes can be readily defined. In pneumothorax the pathognomonic ** bell-sound "
is obtained by this method.

§ 77a. Fallacies in Diagnosis of Diseases of the Chest. — This list includes the most
important fallacies, but it is impossible to make it exhaustive.

1. When the chest wall is very thin the sounds heard on auscultation are propor-
tionately loud. The percussion note is also louder, and it is consequently easy to fall
into the error of supposing that emphysema is present. In children the breath
Bounds are always more distinct than in adults, and are, moreover, more readily con-
ducted, so that adventitious sounds having their origin on one side may even be heard
quite plainly on the other.

2. A chest wall with excess of subcutaneous fat or oedema will give rise to error
if it be not borne in mind that the sounds on auscultation and percussion are alike
deadened and indistinct. The sounds heard over the scapular region are always
less distinct than those heard elsewhere. When a patient does not breathe deeply,
owing to debility or pain on movement of the chest, or when the chest wall is very fat,
the breath sounds may be almost inaudible.

3. The presence of much hair on the chest gives rise to sounds like fine crepitations
as it is rubbed by the stethoscope.

4. The fault of applying the stethoscope to the ear instead of the ear to the stetho-
scope often leads to the chest piece being only in partial apposition to the chesty an

132 THE LUNQ8 AND PLEURM [ § 78

error which causes misleading sounds to reach the ear. The friction between the
rubbers of the stethoscope may originate sounds which are misinterpreted.

5. It is well to remember that dulness on percussion does not necessarily mean
that there is fluid or consolidation present. It may also be caused by thickened
pleura and by the presence of tumours. The latter may be outside the chest, but
pushing up into the thorax — €,g., hepatic or splenic enlaigement, subdiaphragmatic
abscess.

6. Tumours of the chest wall will sometimes lead to the impression that there is
some difference in the size of the two sides of the thorax, and tJiis difference may be
referred to some morbid condition of the chest contents. The swelling caused by
subcutaneous emphysema or bloodclot, both of which may follow an accident, gives
rise to a faint crepitation which may be easily mistaken for the signs of injury to the
lung beneath.

7. When one lung has been long out of action, as in fibroid phthisis, the other
undergoes compensatory enlargement and encroaches on the affected side of the
chest. The hypertrophied lung gives rise to sounds identical with those of emphysema.

8. The breath sounds are better heard and the percussion note is higher at the
right than at the left apex, owing to the presence of the eparterial bronchus on the
right side.

9. Atrophy of the muscular tissues about one shoulder leads to an apparent flatten-
ing on that side very like that seen in phthisis.

10. Peritoneal friction, due to inflammation below the diaphragm, may be mistaken
for pleuritic friction, as it is frequently audible at the base of the lungs, and as far up
as the seventh interspace.

11. Distension of the abdominal organs, as in meteorism, may extend high up into
the chest and simulate hyper-resonance of the lungs. This is especially probable
when the lungs have been drawn up with adhesions or fibroid contraction. A hernia
of the diaphragm with protrusion of the stomach, or the opening of an abdominal
abscess into the chest, may cause amphoric echoes and bell sounds, as in pneumothorax.

12. Dextro-cardia is very rare, but it is necessary to bo on one's guard lest it be
rashly supposed that the heart is displaced by effusion or by some tumour. (

13. Finally it is well to remember that the presence of lung signs usually found in
association with acute disease must always bo interpreted with duo regard to tho
constitutional condition and co-existing signs of disease in other organs.

§ 78. Examination of the Sputum. — Much may be learned from an examination of
the sputum. First, as regards its Appearance. In simple pleurisy, though the
cough is distressing, expectoration is absent (t.e.*, the cough is ** dry "). If the disease
be confined to a moderate catarrhal process of the l^ronohial tubes {e.g., bronchitis),
the sputum is white, clear, and frothy (" mucous expectoration "). If the process
be more severe and suppurative, or if the lung tissue bo breaking down, then pus is
present, and the sputum is yellowish (muco-purulent). Thin watery sputum is ex-
pectorated in large quantity in oedema of the lungs. In phthisis, when the lung is
breaking down, the sputum is often voided in thick purulent masses like coins, hence
called nummvlar. In cases of pulmonary abscesses, tuberculous cavities, and of
empyema bursting into the lung, large quantities of almost pure jma are expectorated
from time to time. Extremely foetid expectoration is voided in gangrene of the lungs
and in bronchiectasis. The latter is distinguished by having large quantities of putrid
ftputum, brought up by paroxysms of violent cough at one time ; while in the intervals
the cough and expectoration are those of bronchitis. The bronchiectatic sputum, on
standing, sepanntes into three layers — ^the upper clear and frothy ; the middle granular,
with mucus ; the lower purulent, with thick ** Traube's plugs " (p. 133). The foul
odour is due to valerianic and butyric acids. In pneumonia the sputum is very
characteristic, being (i.) almost airless and extremely viscid, so that the vessel con-
taining it may be inverted without spilling it, and (iL) tinged with blood, thus having
a ** rusty " colour. In severe cases, and in new growth of the lung, the sputum becomes
thinner, frothy, and dark red, the " prune-juice " sputum. Casts of the bronchial
tubes, which can be seen by the naked eye (Fig. 46, p. 156), are expectorated in plastic
bronchitis, and occasionally in croupous pneumonia, and shreds of membrane in
diphtheria. Hydatid cysts, resembling empty gooseberry-skins, are expectorated

ITS]

EXAMINATION OF THE SPUTUM

in tlut rare oondition hTdatid diaease of the langs, or when hydatid of the liver nip-
tniBB into them. In town dwelleis, uid tboae with doaty oooupAtions, the sputum
is dark, or even blsck. from tiie presenae of osrbonsoeouH and other particles. " An-
chovy sauce " coloured spntum ie oharacteriatic of absceas of the liver which has burst
irtto the lung (| 244).

MiCBOSCOPic EXAHIHATIOK OF THH SpnTUM.^Varioufl hociaia lfi.g., tuberoie,
pneBinococcuB, inBuenza. pyogenic ooooi, anthrax, glanden, plagoe, the fungi of
actinomycosis and ospergilloBiB) may be found in the spntum. The method of detecting
these ia described in Chapter XX.

In all destructive diseases of the lung fngmeata of pulmonary tissue are present
— Le., epithelial cells and connective tissue. The moat characteiistic is eUutie titmt.
Elastic Gbres are best revealed by taking a small portion of the sputum and boiling
it with liquor potasan, which breaks up and randeia clear all tiie other olemente. but
leaves the elastic libiFs unattaoked. Ilieae sink to the bottom of the t«st-tnbe, and
may be withdrawn by a pipette (pieoautions, see Urinary DepoaitB) for eiamination
under the misoroeoope. They appear as wavy, highly
cefractite fibres, of uniform thickness, with square-out
ends, and are typically arranged aa if surrounding au
air cell (Pig. 3S). Elastic tiaaue ia found. in the mouth
after meaU. so the mouth and teeth shonld, M a
precantion, be cleansed before the observation is made ;
bat circularly arranged elastic Gbres are quite distinctive
of breaking-down lung tissue. The Traubo " plugs " of
a bronohiectatic sputum (} 103) are little pellets, which
oontain pua and epithelial oalls, with needle-shaped
fatly-acid ciystala. Sometimes elastic fibres are also
present in small amount. They are believed to he
pathognomonic of bronobiectasia.

CuTtchmajm'a spiraU are found in the sputum of
asthmatio patients. They form pellets or paieg, the
siie of sago grains, which can be uncoiled to form
a thread about an inch long. Microscopically, they are
seen to consist of fine mucous fibrils wound spirally
round a central core of mucus. They are probobly
allied to small bronchial casts (Finlajson). Charcot-
Lofdat crystals (Fig. 39) are colourless, pointed, octa-
hedral ciystals, formerly suppoaed to be pathognomonic
of asthma, but now known to occur in the sputum of
plastic bronchitis also. They are composed oE phos-
phate of spermin. Pcehl considera spermin to be a de- p\g_ 39, chsrDot-Lerdaa

composition product of nucleo-albumin which normally Cryatali.

circulates in the blood. Many diseases (especially nervous)

are asaociated with an excess of phosphate in the system, which, combined with
spermin, may form Charcot-Leyden oiystala. They have also been found in the
blood ot Uoktsmia. HmmiUindm ciystala are brown or yolbw needles or platea,
fonnd in cases of old hemorrhage from any cause. OHcittterin, leitcin, and tyroiin
crystals are found occasionally in oases where the sputum has been purulent for a
long time- Various paratitea [actinomycee, blastomycos, strep (othrix, eohinococous,
Di«toma palmonale, etc.) are sometimes found in the sputum. Saroinie and Oldiura
albicans come usually from the alimontary tract.

Fig. 38.— Elartio Fibroi.

§ 79. ClaniflcattoiL — For practical purposeB diseaees ot the lunga and
pleune, like those of the heart, may be divided into Acute and Chromic,
and each of these may be subdivided into tliose without dulness, those
with duhiess, and those with hypei-n

134

THE LUNGS AND PLEUEjE

[§80

00
CO

Acute.

I. Acute Bronchitis.
II. Dry Pleurisy.

III. Acute Phthisis.

IV. Whooping-cough.
V. Acute Pulmonary

(Edema.

Chronic.

00
00

I. Pleurisy with effusionl §
(and Empyema). J | -

{

II. Pneumonia-

(a) Lobar.

(b) Lobular.

I. Chronic Bronchitis (and
Plastic Bronchitis).

I. Chronic Phthisis^ (and

Fibroid Phthisis).
II. Hydrothorax.
III. Pulmonary Congestion
(or (Edema).

IV. Interstitial Pneumonia.
V. Thickened Pleura.
VI. Cancer and other neoplasms.
VII. Collapse of the lung.
VIII. Syphilitic disease.

I. Pneumothorax.

I. Emphysema.

Paroxsrsmal.

I. Asthma.
II. Acute Pulmonary (Edema (sometimes).

§ 80. The Routine Procedure here resembles in principle that of diseases
of the heart. First, What is the patienCs leading symptom ? If suffering
from lung disease, his cardinal symptom will be one of those mentioned
in section A. Breathlessness and cough are the chief cardinal symptoms.

Secondly, follow this up with a few questions to ascertain the history of
his illness, and especially whether the disease be acute or chronic. Other
important points are whether the patient has been exposed to a " chill,"
and whether there is any ** limg disease " in the family. Do not use the
word " consumption " ; it may frighten your patient unnecessarily.

Thirdly, proceed to the Physical Examination of the Lungs. The
routine method is as follows :

1. Ascertain whether there is any increased rate or other modification
in the breathing or alteration in the shape of the chest (by inspection, and,
if necessary, by measurement).

2. Ascertain if there be any dulness or hyper-resonance (by percussion),

3. Listen to the breath and voice sounds, directing special attention to
any part suspected of disease (by auscultation),

4. Test the voice soimds by palpation,

5. The sputum should be inspected, and, if necessary, examined micro-
scopically.

^ There is no dulness in quite the early stages of some cases.

§80]

ROUTINE PROCEDURE

135

The chest should always be stripped, and it is more convenient to
examine the patient in a sitting posture, if he be not too ill.

If the illness developed gradually, and is of some standing, and un-
attended by marked constitutional disturbance, then turn to Chrome
Pnlmonary Disorders (§ 91, p. 153).

If the illness came on recently and suddenly, accompanied by fever,
quickened respiration, coated tongue, and with marked malaise, then the
case is one of the Acute Pulmonary Diseases, below.

There is one disease of the lungs, Asthma, which comes on in sudden
acute attacks from time to time ; it is chronic, with acute exacerbations
(§ 90, p. 151).

Acute Diseases. — We now proceed to percuss the chest. In all acute
diseases special attention should be directed to the lower and back part
of the chest just below the scapulae. Careful percussion of this region
wiU give us important aid in diagnosis.

Table VI. — Diagnosis op Acute Diseases op the Lungs

AND Pleura.

I. Acute Bronchitis

If. DryPlenrlBy

III. Acute Pulmonary

TuberculOBis

IV. Pleurisy ^^th

effusion

V. Croupous Pneu-
monia

Percussion Note.

Normal

Normal, or scattered
areas of dulness.

Doll

DuU

Auscultation.

B.M. and V.R. normal ; Loud moist relies
and dry rhonchi.

Breath and voice sounds normal ; Pleuritic
friction.

Scattered fine moist rAles may be the only
auscultatory signs.

R.M., V.R., and V.F. diminished ; Pleuritic
friction at early and late stage.

V.R. and V.F. increased ; Bronchial breath-
ing ; Fine or coarse (redux) crepitations.

The acute diseases without alteration in the percussion note, i.e., withaut
dulness, excluding Whooping- cough, which is an infective disorder, and
has no physical signs in the lungs peculiar to it, and Asthma, which is of
a paroxysmal character — are : I. Acute Bronchitis ; II. Dry Pleurisy ;
III. one form of Acute Pulmonary Tuberculosis ;1 and IV. Acute
Pulmonary (Edema.

I. The fcUient complains of a cough, with frothy expectoration, and his
temperature is slightly elevated ; there is no alteration in the percussion note^
but an auscultating the chest, loud rhonchi are heard. The disease is Acute
Bronchitis.

^ In the early phase of this malady there is no alteration of the percussion note, but
as the disease progresses a patohy dulness appears* if the patient Uve long enough.

136 THE LUNGS AND PLEURjE [ § 81

§ 81. Aoata BronohitiSy or inflammation of the bronchial tabes, is cer«
tainly the most common acute disease of the lungs in this climate.

Symptoms, — The disease commences gradually in the course of one or
two days, with a feeling of tightness of the chest, of soreness behind the
sternum, shortness of breath, frequent cough, and slight rise of tempera-
ture, 100° to 101° F. The inflammatory process lasts from ten days to three
weeks, and gradually subsides. The sputum is viscid and scanty during
the first few days, and then becomes thinner, muco-purulent, and more
easily coughed up.

Physical Signs. — The percussion note is unaltered unless, as so fre-
quently happens, emphysema be present also, in which case the chest is
unduly resonant. On auscultation the vesicular murmur is obscured over
the whole chest on both sides by loud rhonchi and moist rales (see Fig. 40)
which are variable and altered by coughing. On palpation rhonchial
fremitus can frequently be felt.

Causes. — Bronchitis is generally attributed to : (i.) A chill ; that is to
say, sudden exposure to cold, with a determination of blood to the interior,
(ii.) Sometimes, however, it is caused by spreading from laryngitis,
(iii.) It is a frequent complication of many of the specific fevers, especially
measles, whooping-cough, and typhoid. It is so frequently present with
the first and last as to constitute an aid to the diagnosis of those diseases,
(iv.) Certain occupations which expose people to irritating vapours and
small particles of dust predispose to acute bronchitis. Thus the cotton-
mill hands and chemical manufacturers frequently suffer from bronchitis.
It is also common amongst cabmen, mariners, and others who are exposed
to all weathers, (v.) It is a common accompaniment of many other
pulmonary diseases, though it may be a subordinate feature ; and (vi.) it
is commonest in childhood and old age.

The Diagnosis is not difficult in most cases, but acute tuberculosis is at
first very apt to be regarded as acute bronchitis. Thevdiagnosis is aided
by the greater elevation, and the intermitting character of the pyrexia in
the former, and by the presence of the tubercle bacillus in the sputum.
The " capillary bronchitis " of children is really a broncho-pneumonia {q.v.) ;
the constitutional symptoms and dyspnoea are much more marked, there
may or may not be some dulness, and the difEerentiation from simple
acute bronchitis is not always easy.

The Prognosis is favourable in adolescence and adult life, and it always
clears up in one to three or four weeks, though it has a special liability to
retujn, and ultimately to become chronic. It is dangerous in infancy and
old age, where the resisting powers are feeble. It is one of the commonest
causes of death in the latter. If an attack of acute bronchitis does not
begin to clear up in two or three weeks, pulmonary tuberculosis should be
suspected, especially if the patient be young.

Treatment. — The indications are : (i.) During the first stage, to promote
the secretion ; (ii.) when the secretion is free, to stimulate the bronchial
mucous membrane ; (iii.) during convalescence, to improve the general

! a ] AOOTB BB0N0HITI3 137

condition so aa to enable the patient to throw off his liability to bronchitic
attacks. At the onset give an aperient and a diaphoretic mixture, with
perhaps a few grains of Dover's powder to soothe the pain. Poulticing
is useful, and emetics are given to children. To promote the flow of
secretion warm alkaline drinks and expectorants such as ipecacuanha and
antimony, together with liq. ammon. acet., are especially useful. When the

secretion is free — that is, after three or four days — stop the antimony,
and administer expectorants, such as ammonium carbonate, syrup of tolu,
senega, and squills (Formula 57). If the patient is of a gouty oi rheu-
matic diathesis, oi the sputum is very tenacious, add potassium iodide to
the expectorant mixtures. The patient must be confined to bed, and will
derive great benefit from the inhalation of steam. In childhood this is
best done by a bed canopy and a steam kettle beside it ; in adults, a kettle

138 THE LUNOS AND PLEURA [ §§ 81a, 82

with a long spout on the fire will suffice. Linseed-meal poultices, a tur-
pentine stupe to the chest, or a covering of cotton wool give great lellef
to the distressing tightness of the chest (see also FormulsB 30 and 68).
During the stage of recovery tonics and cod-liver oil are called for.

§ 81a. Acute Suffocative Catarrh is a disease affecting the whole or a very large
portion of the mucous membrane of the bronchi. It is very uncommon in adults, but
more common in children. It starts acutely, with urgent dyspnoea and cyanosis,
without expectoration, and is usually either fatal or has subsided in twenty-four to
forty-eight hours. Relief is accompanied by a cough, and the expectoration of copious
secretion. The temperature is but slightly raised. It is said to be due to a turgescenco
of the mucous membrane, analogous to urticaria.

II. The patient complains of sharp pain in the chest on inspiration ; he
has a short dry cough, and his temperature is moderately elevated ; on ausculta-
tion, FRICTION is heard. The disease is Dry Pleurisy.

§ 82. Dry Pleurisy is inflammation of the pleura without effusion. In
this disease there is a fibrinous exudation on the visceral and parietal
layers of the pleura, and a tendency to the formation of adhesions, and
to the effusion of fluid.

Symptoms, — The disease in some cases comes on quite suddenly with a
stitch-like pain in the chest. The constitutional disturbance is never very
great, and the patient rarely takes to his bed. The temperature may rise
to 100° or 101° F., rarely higher. The most obvious symptom in this
disease is pain in the chest, affecting one side only in most cases, and
characterised by being greatly increased on deep inspiration. The pain
is caused by the contact of the inflamed pleural surfaces, and is usually,
though not necessarily, located over the diseased part.

Physical Signs, — Percussion reveals nothing. On auscultation, the
respiratory murmur may be found to be normal or shortened, as the
patient endeavours to restrain the movements of the chest on account of
the pain so caused. From the very outset a pleuritic rub is heard over
one side, often most marked at the angle of the scapula (compare § 77).
Sometimes the inflammation undergoes resolution or adhesion, sometimes
it goes on to effusion. As effusion takes place, the pain and pleuritic
friction disappear, to reappear again when this subsides.

Causes, — (i.) Sometimes it is a primary malady, attributed to chill,
especially in persons of a gouty or rheumatic diathesis, (ii.) It may occur
as a complication of some acute infective disease, such as measles or scarla-
tina, (iii.) Inflammation may extend from disease of the underlying
lung, such as pneumonia, tuberculosis, cancer, and embolism, or from
adjacent organs, such as the liver or spleen, (iv.) Undoubtedly a large
number of apparently simple pleurisies are tuberculous in origin (some go
so far as to say 82 per cent.) ; and this fact should always be remembered.

The Diagnosis from muscular rheumatism (pleurodynia) is made by the
tenderness and absence of friction sound in the latter. In intercostal
neuralgia there are tender points along the course of the nerve, and the
pain is not aggravated by deep inspiration. Pleuritic friction is distin-

§ 8S ] ACUTE PULMONARY TUBERCULOSIS 139

goished from the rhonchi heard in bromAUis by there being in nearly every
case of pleurisy a distinct interval between the inspiratory and the ex-
piratory rub.

Prognosis, — It is not a serious malady, and readily yields to treatment ;
but sometimes eSusion occurs (Pleuritic Efhision, § 85). When this
efiusion becomes purulent (Empyema, § 86) the prognosis is grave. Thick-
ening of the pleura may result, especially in tuberculous cases.

Treatment. — CJonsiderable relief is derived by simply strapping the
alFected side of the chest, so as to limit the costal movements of respiration:
This may be combined with some local application ; that which gives
greatest relief is imdoubtedly a linseed-meal poultice. As the disease
becomes chronic, counter-irritants are called for, more especially iodine,
which may be painted on daily until the skin becomes sore. If it does not
disappear in the course of a few weeks, we must suspect some other cause
for the mischief, such as those mentioned under pleurisy with effusion.
Diuretics, diaphoretics, iron, and other tonics are useful.

III. The patient exhibits the signs of subacute bronchitis ; but he has
SEVERE MALAISE and a HECTIC TEMPERATURE, and the sputum may contain
TUBERCLE BACILLI. The disease is Acute Pulmonary Tuberculosis.

§ 8S. Acnte Pulmonary Taberonlosis (acute phthisis, galloping consumption) is a
catarrhal process affecting the entire lung tissue, due to the invasion of the tubercle
bacillus. It is often part of a tuberculous process infecting the whole body, and. is
therefore sometimes described as the pulmonary form of acute general tuberculosis
(see Chapter XV., where a chart is given showing the typical course of the temperature
in both diseases).

Symptoms, — ^The malady is of most insidious onset, with progressive weakness and
emaciation. Some weeks before any physical signs are evident the thermometer
shows the typical intermittent pyrexia so characteristic of tubercle — an evening
elevation of 101 ** to 103*^ F., and a morning normal temperature. In rare cases the
inverse type is present, when the temperature is higher in the morning than in the
evening. Night-sweats and cough are present, with muco-purulent expectoration.
Dyspncea, and sometimes cyanosis, develop out of proportion to the physical signs ;
the latter symptom may be extreme, and of itself is a very characteristic feature.
Great weakness ensues, and in the third or fourth week the patient may develop the
symptoms of the typhoid state.

The Physical Signs referable to the lungs are indefinite, or resemble at first those
of bronchitis. At first there is no alteration in the percussion note, but by-and-by
careful percussion discovers scattered patches of dulness. Auscultation at first may
give little help, but in the course of a week or so it reveals rhonchi and fine r.Uos over
certain areas, which do not shift from place to place, as in bronchitis. Later on the
rales are coarse and bubbling, and areas of tubular breathing may bo found.

The Diagnosis in the first stage from bronchitis and bronoho-pneumonia is extremely
difficult. We have to rely upon the disproportionate emaciation and cyanosis, the
character of the temperature, and the patchy distribution of the physical signs in
tuberculosis. In other cases the malady is almost indistinguishable from enteric fever
except for the marked predominance of the pulmonary signs and the absence of the
roseola, and the Widal test is negative. In all stages the detection of the tubercle
bacillus in the sputum is a valuable aid to' diagnosis, though its absence does not
exclude acute pulmonary tuberculosis. The various tuberculin tests may be tried in
doubtlol cases (§ 94).

Causes. — ^The disease may occur at any ago, but is commonest in young adults, and
in those with a family history of consumption. In some instances acute general

140 THE LUNGS AND PLEURjE [§§ 84,

tuberouloais originates from a primary focus, such as a tuberculous joint, which had
been considered cured. Sometimes the disease follows measles or whooping-cough in
children.

Prognosis. — ^The disease is almost uniformly fatal in about two to twelve weeks-
Treatment is almost entirely symptomatic.

IV. The pcUienty a child, his paroxysms of coughing which frequendt/
terminate in vomiting ; there is very slight feverishness, but the only signs
in the lungs are those of a little bronchial catarrh. The disease is Whooping-
cough.

Whooping-coiigh (Pertussis) is an acute infectious disease, and it is
described among the microbic disorders (§ 368).

V. The patient is suddenly seized with acute dyspnoea and copious frothy sptUutJi
flows from the mouth and nose. The disease is Acute Pulmonary CEdebia.

§ 84. Acute Pnlmonary (Edema. Symptoms. — ^The sudden onset of acute
dyspnoea, with copious, often blood-stained (rose-coloured) sputum, are most char-
acteristic. The diagnostic point about the sputum is that it contains albumen.
The face is pale, the expression is one of intense anxiety ; there may be a cold
sweat. The pulse is feeble, and there may be pain or a feeling of oppression in the
chest. The disease is conjectured to depend on weakness of the left ventricle,
allowing the accumulation of fluid in the lungs. It may arise in the course of
heart disease, more especially aortic disease, arterio-sclerosis, pregnancy, epilepsy,
angio-neurotic oedema, acute infections, or Bright's disease. The physical signs
consist of rales and crepitations which are heard all over the chest.

Treatment. — Sometimes the disease is so rapidly fatal that no treatment is of avail.
The best emergency treatment is blood-letting to 20 ounces. In fulminating cases
this should be undertaken without delay. Atropine and belladonna have an almost
specific action ; yk^ gr. of the former should be given hypodermically at the earliest
possible opportunity, the recurrence of attacks cannot be prevented except in those
cases where the patient is able to foretell their coming. In these a dose of atropine
in time will ward off or very much mitigate the attack. The only prophylactic treat-
ment is directed to the presumed cause of the attacks — i.e., to the underlying disease.
The disease may never recur, but in some patients may persist at variable intervals
for years. ^

We now turn to the Acute Diseases with Dulness on Percussion —
I. Pleurisy with Effusion (Serous or Purulent) ; II. Pneumonia and
IIJ. Broncho-pneumonia.

I. The patierU has a dry cough, vnth moderate fever and other constitu-
tional symptoms. On examining the chest, the respiratory murmur, vocal
resonance, and vocal fremitus are found to be diminished or absent. The
disease is Pleurisy with Effusion.

§ 86. Acute Pleurisy with Effusion. — When describing acute Dry
Pleurisy (§ 82) it was pointed out that the disease may undergo resolution
or result in adhesions. It may also go on to eftusion — Pleurisy with
EfEusion.

Symptoms. — There is usually a history of a more or less acute onset
with pain in the side (§ 82), but as the disease progresses, and the surfaces
of the pleura are separated by fluid, pain becomes less and less marked.

^ Leonard Williams, the Lancet, December 7, 1907, and discussion in subsequent
numbers.

!»} ACOTE PLEURISY WITH EFFV810S 141

The patieDt suffers from general malaise, and finds it diflicult to lie on the
wnitd side, because the action of the healthy lung is thereby impeded.
A degree of breatUessness may be present, but even with a large amount
of fluid this is not invariably a prominent featuro.

Pkyticfd Sigru (see Fig. 41).— Percussion reveala absolute dulneas over
the fluid. Above the level of the fluid, if the lung be otherwise healthy,
there is a hyper-iesonant note (Skodaic resonance). When the effusion
is large it canses displacement of organs, which may be very considerable
(sM Fig. 42). The level of the fluid does not usually shift with the position
of the patient, as it does when there ia non- inflammatory (dropsical) fluid
in the cheat. On auscul-
tation over the fluid, the
breath sounds are absent ;
the vocal resonance is
greatly impaired or lost.^
At the upper margin of the

fluid posteriorly — perhaps

jost about the angle of the

scapula — only the highest

pitched tones of the voice

are transmitted, and they

produce, therefore, a sound

like the bleating of a goat

(^ophony). On palpation,

the vocal fremitus is found

to be diminished or absent t

over the fluid, and there ''

may be bulging of the

intercostal spaces. The

amount of fluid present J

raBybeeetimatedby(i.)the

d^ree of diminution of

the vocal resonance and _

... J ... , ^, Fig. 41.— Dlagnm to

fremitus, and (u.) the L^t"*""^ i>»>uo<i> m

amount of displacement of

oigans. The diagnosis of pleurisy in its earlier stages is referred to under

Dry Pleurisy. The differentiation of the physical signs of fluid in the chest,

as compared with those of consolidation of the luug, is so important that

it is given in a tabular form in § 77. It is sometimes difficult to make out

the left margin of the cardiac area when there is effusion in the left pleura.

Dr. 8. H. Habershon has suggested a very valuable aid in such cases.

Place a vibrating tuning-fork, such as aural surgeons use, in mid-axilla

over the seventh rib. Listen with the stethoscope over the centre of the

cardiac area, and gradually move it towards the tuning-fork, and in other

142

THE LUNQS AND PLBVSX

[sa

B boy >gecl twelve, adml
the care of Sir WIIUsd
in the Wsttetn Innnnsr]
April io. 1805.

directions. As the stethoscope crosses the boundaiy of the heart, there
is a distinct difference in the note heard through the stethoscope, and in
this way the cardiac boundaiy may be
determined.

Course and Prognosis. — In about a fort-
night from the dat« of onset the fluid
usually shows signs of diminution in
quantity, the vocal fremitus and re-
sonance return, and the breath sounda
, become moie audible. This is the usual

course, but several untoward results may
ensue : (i.) The effusion may remain for
an indefinite time, and re-collect after
tapping, (ii.) Adhesions may take place
between the two layers, and considerable
thickening of the pleura result, (iii.) The
fluid — especially in children after scarla-
tina— may become purulent (Empyema,
^a^°^Z see below).

f'o^B^dn'" Treatment.— To get rid of the effusion
', aioagow, pui^atives, diuretics, and diaphoretics
(potassium citrate and bitartrate, potas-
sium nitrate, liquor ammonife acetatis,
etc., Formula 55) are often efficacious.
Counter-irritants may be useful. Iron and
other tonics arc useful. Autoserotherapy
has had success abroad in pleural and peri-
toneal effusions. One to ten c.c. of the
serous fluid are aspirated ; the needle is
withdrawn as far as the subcutaneous
tissue, where its contents are injected.
If these measuies fail after a few weeks'
trial, paracentesis should be performed
(Figs, 42 and 4-3). Under certain con-
ditions it is inadvisable to delay para-
centesis : (i.) A laige effusion {e.g., with
duluess extending upwards as far as the
third rib ; (ii.) cardiac embarrassment,
laiiy Pot. d't. Br', x. Pot. as evidenced by cyanosis, palpitation.

Patient alia Lad dianimea at tiiia barrassment, flhown by urpent dyspnoea
and paroxysmal attacks of coughing ;
(iv.) effusion in the other pleura, or oedema of the other lung. It should
be remembered, in recurrent effusion, that tubercle may be the cause.

Paraeenten) ThoracU. — The inxtramont used is an adaptation of the familiar trocar
and cannula. We aro here dealing with a, cavity whowi contents are under a minus
prmsuro, so it ii nacossaiy bo have a pump or exhausted bottle cotnmuuiaating with

Fla. «S.— Showi altered atste of du
UDder lue ol dlnretia <A]irll
Un. hydrarg. was applied, am

f 86 ] EMPYEMA 143

the trocar. The site of puncture — usually the seventh interspace in the posterior
axillary line — should be cleansed with acetone or other strong antiseptic. The needle
of the aspirator should be boiled. The bottle or chamber of the syringe is next
exhausted of air. If the point of the instrument be not very sharp, it is desirable to
make a nick with a scalpel in the skin, previously pulled downwards over the rib below.
Then the instrument is thrust into the intercostal space boldly at the acme of an
inspiration. Communication is then established with the bottle or syringe, the flow
being regulated by the tap or piston, so that the outflow may not be too rapid. Much
coughing by the patient indicates that the point is touching the lung. A quantity
varying between 5 and 50 ounces may be withdrawn, but the operation must be
stopped if coughing or respiratory distress is caused. Seal the opening with collodion.
At the present day siphonage is preferred to the aspirator by some. If the fluid
contain blood, it may denote a slight wound of the liing or carcinoma, or occasionally
tubercle. If it be purulent, the surgical measures for empyema are applicable, and it
is wise to be prepared for this eventuality. In cases of serous effusion. Sir James Barr*
recommends that the fluid should be withdrawn by siphonage, and replaced by about
half to three-quarters of its bulk of sterilised air. When all the liquid is withdrawn, he
injects 4 c.c. of adrenalin (1 in 1,000), diluted with 10 c.o. of sterile normal saline.

la. The physical signs are those of pleurisy with elusion, hU it does not
dear up in due course, and the patient has sweatings, shiverinos, and
ntREOULAR ELEVATIONS of temperature. The disease is probably Empyema.

§ 86. Empyema is a collection of purulent or sero-purulent fluid within.
the pleura. It most often follows a serous effusion, but it may be purulent
from the beginning.

The Symptoms and Physical Signs are similar to those of serous effusion
(q.v., supra), with certain others in addition — viz. : (1) It may be foimd
that the fluid does not dear up as & serous effusion should do, and thus the
presence of pus may be suspected. (2) Whenever pus forms, either in the
pleura or elsewhere, it is marked by the occurrence of sweatings, shiverings,
and an intermittent pyrexia. (3) (Edema of the integument, the pointing
of an abscess in an intercostal space, over the clavicle, or even in the groin,
or copious discharge of pus by the mouth, are in rare instances the first
distinct evidence of a localised empyema. (4) The history generally
throws considerable light on the case by revealing one of the cat^es of em-
pyema— namely :

(i.) Pneumonia, especially in children, may be followed by empyema ^ ;
(ii.) septic conditions of the pericardium, mediastinum, or respiratory
tract — sepsis in any part of the body may cause a simple effusion to
become purulent ; (iii.) tuberculosis in any form in the thorax ; (iv.) the
acute specific fevers ; (v.) abscess of the lung — e.g., in bronchiectasis —
abscess of the liver or spine bursting towards the pleura, or peri-hepatic
abscess resulting from appendicitis, leaking gastric or duodenal ulcer;
(vi.) careless paracentesis, or any wound from without, permitting the
introduction of organisms.

(5) In doubtful cases a leucocyte count should always be made, since
in the absence of acute lobar pneumonia more than 20,000 leucocytes per
cubic millimetre would strongly favour a diagnosis of empyema. (6) The

^ See Bradshaw Lecture, Brit. Med. Journ., November 9, 1907.
2 In children there* is often rapid onset of pus without constitutional signs, as in
Pyopericarditis (§ 38a).

144 THE LUN08 AND PLEURJE [ § 86

agpiration of a few drops of the fluid with a hjrpodermic needle will often
settle the diagnosis, though there are two fallacies in this method : first,
in rare cases the fluid may be too thick to come through the needle ; or,
again, the pus may be encysted between the lobes of the lung. In any
case, an examination of the point of the needle may assist the diagnosis.

Prognosis. — Empyema is always serious, and may run a somewhat pro-
longed course of some months. Cases of pure pneumococcal empyema are
much more favourable than those due to streptococci or staphylococci,
either alone or with the tubercle bacillus. Its course can be considerably
modified by prompt and adequate surgical treatment. Early operation,
adequate drainage, and strict aseptic precautions, both at the operation
and at the subsequent dressings, are the points in treatment which most
favourably influence prognosis. If left to itself, the results vary : some-
times there is compression and destruction of the lung ; sometimes there
is a falling-in of the side of the chest ; sometimes, as above mentioned, the
pus opens into the lung or burrows in various directions ; sometimes it
opens through the chest wall ; or it may become partially absorbed, and
result in a caseous mass.

Treatment, — When we are sure that the fluid is purulent the empyema
should be opened and drained without delay. Every aseptic precaution
should be taken. To drain an empyema it is usually necessary to remove
1 to 1| inches of rib, which is best taken from the seventh or eighth rib
in the posterior axillary line. When the patient is anaesthetised, insert a
needle in order to locate the pus. This should determine the site of the
operation, a point being selected in as dependent a position as possible.
The skin is pulled down with the finger, and an incision is made 3 inches
long on and parallel to the rib. The periosteum is scraped oS with a
raspatory, and the piece of rib removed with strong bone forceps. The
parietal pleura is then incised. The intercostal artery situated just
beneath the lower border of the rib should be avoided ; if cut, it must be
ligatured. The finger should be introduced into the cavity as soon as it
is opened and before the pus has drained away. By this means any
adhesions may be gently broken down and the large fibrinous flakes of
pneumococcal empyemata be removed. Drainage should be effected by
means of a large tube, which can usually be shortened to 1 inch or so after
about forty-eight hours. At subsequent dressings the same strict asepsis
should be maintained, because secondary infection makes the prognosis
much worse. In the case of very large empyemata, causing great embar-
rassment, it is sometimes advisable to remove some of the pus by aspiration
as a preliminary measure, but this should be followed by operation after
about twelve hours.

II. The fotient has been taken ill suddenly ; the temperature is high^
the dyspncea considerahUy and the expectoratum soon becomes rusty ; there are
signs 07 ooNsouDATiON ot the bose of one lung. The disease is Acute
Lobar Pneumonu.

S 87 ] PNEUMONIA US

§ 87. PaeDmonia — i.c., inflammatioii of tlio pulmonary tissue prd^r,
or parenchymatous inflammation — occurs in two forms. The firgt ami
more acut« is, from its area of distribution, termed " Lobar Pneumonia,'*
or, from the nature of the inflatntnatlon, " Croupoua Pneumonia." The
second is termed " Lobular Pneumonia," because it affects the lobules of the
lungs (also called Broncho -pneumonia. Catarrhal Pneumonia ; see below).

Aoste Lobar Pneoinoiua commences suddenly, with well-marked con-
stitutional syraptoma, such as headache, backache, rigor, and, in children,
vomiting. The temperature during the rigor rises to 103° or 104° F., and
it remains at this point for about a week (Fig. 44). The aspect of a pneu-
monia patient is very characteristic (§ 7)-~the face is flushed, and herpes
often appears on one side of
the mouth. There is pain in
the affected side, short cough,
shallow, rapid breathing, and
on the third or fourth day
tenacious rusty-coloured
aputum. The pulse -respira-
tion ratio is 2 to 1, instead
of the normal 4 to 1. The
urine is scanty, high-coloured,
with diminution of the
chlorides. The patient shows
more and more distress, and
in a short time there may be
delirium, with signs pointing
to failure of the heart.
About the sevetUh or eighth
day the fever, in favourable
cases, terminates by crisis,
falling to normal in the course
of a few houre. This ia accom- •■■'» "■-■*«i^^* ^=^ >l'"'J"^°'"t- '^*""'S *="^*=^

crlua on tins aevaatb day, Ueorge H.. ssed
panied by marked genera! Uiirty-Uve, wm taken iU very inddenly when Lii

improvement; the pulse- ude.

respiration ratio returns to

normal, and a critical sweating or diarrhcea may occur. Crisis often
occurs on the odd days — i.e., fifth, seventh, ninth, or eleventh of the
disease. Pseudo-crises occasionally occur, but these are distinguished
from true crises by the fact that the pulse and respiration do not
return to normal. In rare cases the temperature falls by lysis. The whole
illness lasts about two or three weeks. If it lasts longer, tuberculotia
shotdd be autpeded (§ 87 a).

The Physical Signs are limited to one lobe or one lung, usually the right
lower lobe. It is only in rare cases that both lungs are aSected. Pereus-
aioQ may, for the first day or two, reveal no dulneas, but, as a rule, there
is elicited early in the disease slight impairment of the percussion note,

146 THE LUN08 AND PLEURM { § SIT

which soon becomes dull. On auscultation, the breath sounds are weak,
and fine rustling crepitations are heard, which have been compared to the
rustling of hair or tissue-paper against the ears. As the inflammatory
exudation increases, the lung tissue becomes solid, and over the dull area
we get all the signs of consolidation (p. 131). When the fever abates, coarse
moist rales (redux crepitations) are heard, and the percussion resonance
and normal breath sounds gradually return.

Etiology, — Pneumonia occurs at all ages and in both sexes, but is com-
monest in adult males. It is a microbic disease, the specific cause being a
diplococcus, the pneumococcus of Fraenkel. Debilitating influences, such
as exposure, are said to predispose to the disease ; but it is surprising how
often strong, apparently healthy men are attacked, and these not infre-
quently succumb. A blow on the chest may determine an attack. Like
other local inflammatory diseases, it may arise as a complication of a con •
stitutional malady ; the acute specific fevers in particular rendering a person
vulnerable to the pneumococcus. When pneumonia runs an atypical
course we should always bear in mind the possibility of the lung afEection
being only a complication of a constitutional disease such as typhoid fever.

Diagnosis, — Pneumonia is diagnosed from acute pleurisy with effusion
by means of the data given in the table of diagnosis between consolidation
of the lungs and fluid in the pleura (§ 77). Broncho pneumonia runs a
different course, and the signs are scattered over both lungs (see table
below). The sudden onset of acute pneumonia resembles that of scarlet
fever, erysipelaSy and smaV^pox, but the absence of rusty sputum and altered
pulse-respiration ratio distinguishes them. There is a pneumonic form of
acute pulinonary tuberculosis which has to be borne in mind (§ 87a) ; also
various aberrant forms of pneumonia (§ 876). Pneumonia jnay at its onset
simulate abdominal inflammation^ pain being referred to the abdomen, and
lung signs being absent (§§ 164 and 169).

Table VII. — Differentiation between

Lobar or Croupous Lobular or Broncho-

Pneumonia. PNEUMONIA.

Onset . . . . Suddon, with rigors . . Gradual, and procodod by

bronchitis.
Course of Tempera-
ture . . . . Continuous . . . . Remittent.
Defervescence . . By crisis seventh day . . By lysis in three to four weeks.
Percussion . . Dulness in one lung, usually Scattered patches of dulnese

the base. in both lungs.

Auscultation .. (i.) Fine crepitations .. (i.) Fine crepitations and con-

(ii.) Consolidation signs in a solidation signs over dull

day or two. areas, though obscured by

rhonchi and bronchi tic rales.
Sputum . . Rusty . . . . Frothy and muco-purulent.

Respiration . . Pulse-respiration ratio 2:1. No marked difforonoe of pulse-
respiration ratio.

Prognosis, — The case mortality varies from 20 to 40 per cent, in hospital

cases. The usual mode of termination is by heart failure. Much depends

on the position and extent of the lesion, which is graver when both lungs

§ 87 ] PNEUMONIA 147

are involved or when the disease attacks the apex. The reason for Uiis
is that apical pneumonia usually occurs in a lung already damaged by
tubercle. It must, however, be remembered that small areas of consolida-
tion may be associated with very great toxaemia. A lethal termination
may be anticipated with marked cyanosis, a typhoid condition, scattered
rales over both bases (indicating oedema), with lowered temperature.
The absence of the usual increase in the leucocytes is of the gravest import.
Pneumonia is graver at the extremes of life, in alcoholics and in debilitated
persons; but robust men in the prime of life often succumb, although
the prognosis is generally stated to be good in healthy adults. As regards
complications, meningitis is generally fatal, and endocarditis extremely
grave. But of all conditions influencing the prognosis of lobar pneumonia
chronic alcoholism is, in my belief, the worst.

Tteatment. — There is at present no specific remedy for pneumonia, so
that treatment is mainly expectant. Our chief endeavour should be to
maintain the patient's strength, and to achieve this, rest in bed, good
nursing, and visits by the doctor at least twice a day are essential. Patients
treated near an open window have less dyspnoea and cyanosis, and sleep
better than those treated in a vitiated atmosphere. They should be kept
thoroughly warm by blankets and hot bottles. The diet must be fluid,
2 to 3 pints of milk, into which may be stirred three or four eggs, being
given in the twenty-four hours. Sleef is of such paramount importance
that no patient should be allowed to spend a restless night. The cause for
the restlessness should be sought for and treated. Frequently pain is the
disturbing factor. This may be relieved by the local application of ice,^
fomentation, or poultices, or a leech. Another cause of sleeplessness is
engorgement of the right heart. In every case of pneumonia careful watch
should be kept over the right heart. If the patient is blue and restless,
the cardiac dulness increased considerably to the right, the liver enlarged,
and the veins of the neck full, we should immediately relieve the right
heart, either by venesection (about 5 ounces) or by applying six leeches to
the skin over the liver. This extreme condition may be averted by the
timely use of two or three leeches. Pyrexia over 103° may be the reason
for sleeplessness, and may be reduced by tepid sponging, a measure which
next to the relief of pain and engorgement of the right heart is the most
satisfactory means of procuring sleep. For the sleeplessness, hypnotics,
such as paraldehyde, trional, or veronal may be given, but never chloral
or sulphonal. Opium may be used in the early stages of the disease, and
is often of the greatest value, its sedative effect more than counterbalancing
its action as a cardiac depressant.

General and Cardiac Stimulants. — Strychnine should be injected hypo-
dermically, beginning with 3 minims of liquor strychninae every eight

^ Dr. Lees oUims that the ioe-ba^ has a direct inhibitory action on the pneumonic
process in the area of lung over which it is applied. Two ice-bags should be placed,
one in front and one behmd, directlv on the skin. The legs must at the same time
be kept warm by hot water bottles ( * The Treatment of Some Acute Visceral inflam-
mations, and other Papers," 1904).

148 THE LUNGS AND PLEURJS [ §{ 87o. 876. 88

hours on the fourth day, gradually increasing the dose according to cir-
cumstances, until the crisis is over. Digitalis is of less use, but may be
given if there are signs of cardiac muscular weakness. Ammonium car-
bonate affords an additional and rapidly-acting stimulant. Concerning
alcohol, there is much difference of opinion. It is particularly indicated
in alcoholic patients, for whom it should be used freely, and especially
in conditions of collapse near the crisis, when it may tide the patient over
so that he is out of danger before the subsequent depressing effect of the
drug becomes manifest. Atropine is helpful, but tends to increase the
delirium. Oxygen inhalations should be tried for the respiratory distress.
Concentrated oxygen is an irritant, and should therefore be diluted with air.
Vaccine treatment is being tried. A dose of 50 million pneumococci,
followed by one of 100 million in twenty-four hours, does good if given
at the beginning of the disease.^

§ 87a. A Pneomonic Form of Acute Pulmonary Tuberculosis, or pneumonic phthisis,
is sometimes met with. The symptoms resemble those of pneiunonia, and may start
suddenly with a rapid rise of temperature and pain in the side. The temperature
may continue high for a week or so. The physical signs also resemble those of pneu-
monia. It differs from this dieoaso, however, in the presence of tubcrolo bacilli in the
sputum, and the temperature, instead of falling abruptly by crisis about the seventh
day. graduaUy becomes intermittent, and the course of the disease becomes indefinitely
prolonged for weeks. This is followed by physical signs of breaking down, purulent
expectoration, night sweats, and generally death in five to twelve weeks from ex-
haustion, haemoptysis, or complications, such as pneumothorax (§ 94).

§ 876. Aberrant Acute Pneumonias (Deuteropathic Pneumonia). — We have seen
that in pleurisy, acute lobar pneumonia, and in other inflammatory diseases of the
lungs, the course of the malady is fairly definite, and the physical signs in the lungs
aie characteristic. But it is important to remember that these same conditions may
occur secondary to, or as part of, some general disorder. Under these circumstances
some of the symptoms or physical signs may be wanting or irregular, and it may not
fce possible to arrive at a diagnosis, except by passing in review the whole history of
the case, and by making a thoruugh cmd systematic examination of all the other
organs. Instances of this eccentric group of pneumonias ai'e met with in acute
glanders, plague, anthrax, syphilis of the lung, actinomycosis, and psittacosis.

The practical outcome of the m considerations is that when a case of pneumonia, or
other apparently local inflammatoiy condition, is atypical in its physical signs or its
clinical history, we probably have to do with a manifestation of one of the conditions
just mentioned, or some general disease, such as enteric fever, scarlatina, pyasmia, or
other general infective disorder.

III. The iUness has come on somewhat gradually ; there is cough, wUh
frothy expectoration ; the physical signs of consolidation are scattered
and accompanied by signs of bronchitis. The disease is frobahly Broncho-
pneumonia.

§ 88. Acute Lobular Pneumonia, or Broncho-pneiunonia (catarrhal
pneumonia), is also an acute parenchymatous inflammation of the lungs,
but it runs a very different course to that of acute lobar pneumonia. The
inflammatory process occurs in small patches, scattered unequally through-
out both lungs, and it is accompanied by bronchitis : hence its name.

The Constitutional Symptoms come on more gradually in this disease.
I'he temperature is remittent, about 100*^ F. in the mornings and 101° to

i Nathan Raw, The Lancet, March 9, 1912.

§ 88 1 AOUTE LOBULAR PNEUMONIA 149

103^ F. in the evenings, accompanied by cough, dyspnoea, and frothy

sputum. The pulse is rapid, but the pulse-respiration ratio is not altered

to anything like the extent of that in lobar pneumonia, ^nd the face is

generally pale instead of flushed. The fever is maintained by the fresh

implication of neighbouring lobules for about three t-o six weeks or longer.

Physical Signs, — When the patches of consolidation are small, there

may be no dulness on percussion, but only tubular breathing ; but when

they are of moderate size, signs of consolidation (§ 77) can be made out.

The chief auscultatory signs in children consist of i/ntensdy loud, *' conso-

nating,*' r^es and rhonchi.

SUology. — ^Bronoho-pneumoiiia oooara at all ages, bat is eapeciatty frequent in
90ung children. The cases fall into two groups, primary and secondary. Primary
broncho-pneamonia, due to the pneomoooocus, arises in much the same way as lobar
pneumonia. Secondary forms arise : (i.) Complicating acute infections, such a^
measles, whooping-cough, diphtheria, small-pox, influenza, tjrphoid and scarlet fevera ;
(iL) complicating chronic debilitating conditions, such as chronic Bright's disease,
chronic cardiac disease, or bed-lying, as from fracture of tho femur in old people ;
(iii.) aspiration or deglutition pneumonia, such as occurs after operations on the
tongue, mouth, or nose, in quinsy, cancer of the oesophagus communicating with tho
air-passages, bronchiectasis, and following hsemoptjrsis or the passage of food down
an insensitive trachea, as in post-diphtheritic paralysis. A common but more chronic
variety is of tuberculous origin.

Diagnosis. — Chronic phthisis is limited to the apex at first, and runs
a characteristically chronic course. The pulmonary signs of measles,
whooping-ooughy and bronchitis resemble broncho-pneumonia in its early
stages, and it may not be easy to diagnose these several diseases until the
rash of the one or the whoop of the other appears. The constitutional
symptoms in acute bronchitis are much less severe. The diagnosis from
acute miliary tvbetculosis may be very difficult, as sputum is usually not
obtainable, but if it can be examined, the tubercle bacillus will be found.
The diagnosis from lobar pneumonia is given in tabular form above (p. 146).

Prognosis, — The case mortality in children under fiy^ varies from 30 to
50 per cent. (Osier) ; the younger the child the more fatal is the disease.
The strength of the patient and the duration of the disease are leading
factors in the prognosis. If he is debilitated, especially if the environ
ment is unfavourable, he soon becomes a prey to the tubercle bacillus,
and the case rapidly runs on to phthisis (q,v.). Similarly, the longer the
case lasts the more likely is it to have a fatal termination, and in adults
this is very often the case. Broncho-pneumonia is nearly always
secondary,, and the third leading factor in the prognosis is the nature of
the antecedent disease. When a child weakened by a prolonged fever is
attacked, the prognosis is very grave, but after whooping-cough and
measles it is much more favourable. Nevertheless, children often recover
in apparently hopeless cases. The aspiration and deglutition pneumonias
are usually fatal.

Treatment resembles that of lobar pneumonia, but stimulants are indi-
cated from the outset of the disease ; two drops of brandy for every month
of an infant's age may be given every second hour. Children should be

THE LVNOS AND FLEURX

[!«

placed in a steam-tant, and email frequent doses of tr. belladomue ad-
miniBteied. For adults the pain and incessant cough may require opium,
beat given as Dover's powder, and poultices applied to the back give
considerable temporary relief. The cheat afterwards maj' be covered
with a cnttoQ-wool jacket. If the symptoms become more distreasing
and the cough and dyspnn'a inrreasc, stimulating pxpectoranltt should bo
ordered ; and if the c^ugh continue difficult an emetic may be given.
For the reduction of the hyperpi-rexia, cold sponging may be adopted,
especially if ceiebral symptoms are present.

We now turn to the acnte diflean with hypcr-naonanoe on peronaiion
— vi^., Pneumothorax. We must bear in niind that an acute diseane
may supervene upon a
chronic condition accom-
panied by hyper- resonance
—e.g., when acute bron-
chitis supervenes on emphy-
sema (see Table IX., § 102).

The patient it in marked
DISTRESS, tchick has come on
SUDDENLY ; there is hyper-
resonance and absence of
breath sounds. The disease
is Pneumothorax.

TyroptnlUc per-
cDUlaa : sbwDot
of brenth tad

Fig. 46.— Dlisnm ot HmsoniBCHOiBOKAX.

S 89. Pnanmotlionx is a term
used to denote the preaanoe of ai r
in Che pleural oavity, the air
having gained admiuion by per-
foration of the ploura, ^ther from
within or from without. Theairii
after a time acoompanied by pug,
and the condition ia tboD known
aa pyopnoamo thorn ; if accom-
panied by aeroua effusion, as
hjdiopoeumothonx (Fig. 46).

The Symplonu of the onset of
tho condition differ aoooiding
to the condition of the lung —
).«., whether it is fairly healtJtj or is widely diseoMd. (a) When pneumothorax
occurs in the less aSeoted of the two lungs — the other side being extensively diseased
— (he symptoms am very urgent, and consist of severe pain in the side, attended by
great dyspntBa, shallow, quick breathing, cyanosis, and some degree of collapee, with
sweating, lividity, and a weak pulfo. Tho patient usually lies on tho healthy side.
(b) Id other cases, whoro pDeumotbomx comes on in a lung which ia already much
disestod, the onset may bo hardly noticed.

The Phi/aical Signa oonsiet of : (J.) A bulging on the afFected side ; (ii.) diminisbad
vocal tnmituB; (iiL) hyper-rosonanco on peroussion (unless then is very great dls-
tension, when the note may be dull) ; (iv.) on ansoultatbn the rospiratory murmur
may either be inaudible or amphoric ; the vocal resonance is ustuJly diminished, but
pectoriloquy and bronchophony Bie sometimes present The bdl soujid may be
elicited on tapping the chest with two coins in one position, and listening with a
stethoscope in another. When fluid i« also pieMDt, and this is uaual, metAlUo tinkling

SM] PNEUMOTnORAX^ASTHMA 151

is heard. Tho Succcuasion SpUuih, when it oan be elioitod without damage to the
patient, is tho meet charactoristic sign of hydropneumothoraz — a fact which was well
known to Hippocrates.^ It may be obtained by placing one*s ear against the chest,
and shaking the patient's body to and fro.

Etiology. — (i. ) Undoubtedly tho commonest cause (75 per cent. ) is advanced phthisis,
when a cavity bursts into tho pleura, (ii.) Tho converse process may take place in
ompyema, when the pus bursts into the lung, (iii.) A fractured rib may lead to per-
foration of the pleura, (iv.) Lo.<» common causes are gangrene of the lung, abscess
connected with the spine or liver, or an ulcer of the stomach or cesophagus. bursting
into tho pleural c^ivity. (v.) It rarely happens in healthy people, although cases have
been recorded. *

Proffjtosis, — ^The occurrence of pneumothorax is always very grave. It is difficult
to estimate its case mortality, because death may be sometimes produced by tho
condition of the lung apart from the accident, but about half die within the first
week, and some in a few hours, from shock or suffocation, when tho lung on which the
patient has been mainly dependent gives way. Only about 10 per cent, of all cases
taken together ultimately recover. The immediate risk depends upon the uigency of
tho dyspnosa and cyanosis, tho state of the other lung, the patient's general health,
and the cause of tho accident. As regards the cattse, the pneumothorax that results
from late phthisis or gangrene of the lung is very fatal ; but that which occasionally
complicates whooping-cough, pneumonia, early phthisis, and injury, often results
in recoveiy. Certain it is that the longer the patient lives after the onset of tho
pneumothorax, the better is the prognosis for ultimate recovery (p. 164). Doath
usually occurs from shock and suffocation, as mentioned above, or from asthenia,
due to the prolonged discharge and lung disease.

Treatment. — A h3rpodermio of morphia is desirable for the pain, and stimulants
for the collapse. The question of paracentesis for the removal of air is important.
It has been done with advantage when groat distension is present, as indicated by
marked displacement of organs, extreme pain and discomfort, but the relief is usually
only temporary. When pus is present, the treatment should be that of emp3rema.
If clear fluid is present, it may be aspirated. In other cases it is inadvisable to
aspirato or operate, especially in phthisical cases, which should be left to the
vis medicairix naturas.

There is one disease of the lungs which belongs neither to the acute nor to
the chronic category, but is paroxysmal, occurring in attacks of sudden
onset, usually withoxjt elevation of temperature — Asthma.

§ 90. Asthma is characterised by paroxysmal attacks of very severe dyspnooa,
the inspiratory effort being short, the expiratory prolonged. It is accompanied
by much lividity and distress. Chronic bronchitis is liable to complicate asthma,
but it is important hero to draw attention to the frequent error which is made by
regarding exacerbations of chronic bronchitis as paroxysms of asthma.

Symptoms and Clinical History, — ^The leading characteristic of this disease is its
paroxysmal nature. A person who is subject to asthma may be perfectly well at
one minute, and half an hour later may be seized with the most violent dyspnoea.
It often commences in tho early mom ng, the patient awakening with a fooling of
tightness of the chest ; he gasps for breath, and clings to surrounding objects in order
to bring into play the extraonlinary muscles of respiration. Each attack lasts from
a few minutes to a few days, and then, without apparent reason, the patient rapidly
recovers his normal and healthy condition.

There are many curious and unexplained features in connection with this malady,
one of the most interesting being the tendency to skin eruptions (especially urticaria
and the various forms of erythema), and another the fact that these eruptions may
alternate with the attacks of dyspnoea. Varioiis other neuroses, and even attacks
of insanity, may alternate in the same way. The paroxysms of asthma are occasionally
preceded or ushered in by violent attacks of sneezing, by itching, or by tho passing

^ " De Morbis," lib. ii., cap. xvi.

' Transactions of the Medical Society, 1897, vol, xx., p. 120,

162 THE LUN08 AND PLEURM { § 90

of large quantities of limpid urine. Sometimes an attack i« terminated in this

Phymcid Signs. — On inspection the cheat is seeii to lie maintained in a ]V)8ition of
inspiration, nndnrRoinR )»ut little expansion wiMi the short inspirations. The per-
cussion note may be unaltcrv-il, but, after many attacks, emphysema supervenes,
with consequent hyper-resonanoe. On auscultation the short inspiratory effort is
feeble and scarcely audible ; expiration prolonged. Loud rhonchi replaee the normal
vesicular murmur and often coarse r.iles, owing to the accompanying bronchitis.

Etiology, — Some regard the asthmatic attack as a series of spasmodic attempts
on the part of the diaphragm, intercostal muscles, and extraordinary muscles of
inspiration, to overcome some obstruction to the entry of air. But the central fact,
which alone explains all the symptoms, is a narrowing of the bronchial tubes. This
is probably due to spasm of the involuntary bronchial muscles, which is attended
by hyporsemia of the submucosa and swelling of the mucous membrane. Some hold
that the latter is the primary condition, and that the disease is therefore an
angioneurosis.

Among the predisposing causes we find : (i.) A neurotic family history. Careful
inquiry may reveal asthma or other neuroses, especially those so-called functional
diseases of the nervous system connected with the involuntary muscular system,
such as attacks of flushing and shivering, faints, and the like, (ii.) Asthma may
occur at any age, but nearly always makes its first appearance soon after
the ago of puberty, (iii.) Any previous lung disease, especially chronic bronchitis,
may predispose to asthma. Malaria, gout, and other constitutional conditions, are
often associated with it. (iv.) Conditions of the nasal passages, such as ulceration,
hypertrophic rhinitis or polypi.

Among the exciting causes of an attack may be mentioned : (i.) Certain atmo-
spheric conditions which are ill-understood, and often appear to be most contra*
dictory. Thus I know one patient who is free from asthma • n London, but develops
an attack immediately she seeks a high altitude. Another always develops an
attack when she enters London. Some find the sea relieves them, others that a seaside
place determines their attacks, (ii.) Reflex causes, such as derangement of the
alimentary canal, and dietetic indiscretions {e.g., the eating of cheese or fish), will
often determine an attack ; and so also will (iii.) dust and irritating particles.

Diagnosis. — ^The diagnosis usually presents no difficulty. The paroxysmal occur-
rence of the disease is quite characterist c. Paroxysms of dyspnoea coming on at night
are apt to occur in the course of Bright*s disease and cardiac disease, and have been
loosely called asthma.

Prognosis. — ^The disease of itself does not shorten life, but tends to produce emphy-
sema, bronchitis, and their attendant evils. Children may grow out of the disease ;
adults never lose it completely. The severity and frequency of the attacks are our
only gruides to prognosis.

Treatment. — (a) During the Attach. — Various remedies have been tried. Mentioned
in the order in which I have found them most useful there are : tr. lobelia, belladonna,
hyoscyamus, opium in small doses, and pyridin, a remedy introduced and strongly
advocated by Germain See. An injection of 5 minims adrenalin (1 in 1,000) may
abort an attack. Spraying the nose with the solution is often efficacious. Atropin
and cocaine sprays also relieve. The diet during the attack should be the lightest
possible ; milk alone is best. Various inhalations are sometimes useful, either for
the prevention or relief of an attack — e.g., the vapour from a teaspoonful of turpentine
and chloroform in equal parts, or the fumes of paper prepared with a strong solution
of nitrate of potash, or the inhalation of amyl nitrite. If a mixture containing equal
parts of the leaves of stramonium, lobelia, black tea, and potassium nitrate, be burnt
in a tin plate, and the fumes be inhaled, much relief is usually afforded. Various
other preparations, in the form of cigarettes of stramonium, potassium nitrate, and
belladonna, are used.

(h) Between the Attacks. — The effect of locality on the disease can only be ascer-
tained by experience, and, as above mentioned, it is impossible to foretell what effect

* These facts point possibly to an infection of the general vaso-motor system similar
to that in the pulmonary system which produces the spasmodic dyspnoea.

§•1]

CLASSIFICATION

153

a particular climata will have. As a rule, though with many exceptions, town air
and fogs are detrimental. To prevent an attack, special attention should be directed
to the diet, light nourishing food should be advised, and the avoidance of solid
meal<« after two o'clock in the day. Iodide of potassium, administered for a long
period of time, certainly tends to ward otf attacks in some patients, and potassium
bromide at bedtime may act similarly. Ai^senic also is very aseful. The nose should
bo examined for polypi, etc., and these, as possible causes of irritation, must be
removed.

CHRONIC DISEASES OF THE LUNGS AND PLEURA.

§ 91. GlassifioaiioiL — Chronic disorders of the lungs and pleurse msy
follow an acute attack of the conditions described in the previous sections,
as when chronic bronchitis and emphysema succeed attacks of acute bron-
chitis. But many of the chronic diseases of the lungs, such as pulmonary
tuberculosis, start insidiously, and attention may not be directed to the
lungs for a considerable time.

The chronic diseases, like the acute, may be classified for clinical pur-
poses, according to the results of percussion. It is convenient in actual
practice, although unscientific, from the point of view of classification, to
make a subsidiary group in which the sputum is highly offensive or has
some other characteristic feature.

(a) Chronic Disease in which the Percussion Note is unaltered :

I. Chronic bronchitis

(b) Chronic Diseases attended by Dolness on Percussion :

The commoner disorders presenting dulness in regular and

areas either at base or apex are —

I. Chronic phthisis

TI. Hydrothorax . .

TIL Pulmonary congestion (or cedema of the lungs)

The rarer diseases, having irregular and senlterei ai^as of dulness aro —
IV. Interstitial pneumonia
V. Thickened pleura
VI. Cancer and other neoplasms
VII. Collapse of the lung tissue
VIII. Syphilitic disease of the lung
(IX. Mediastinal tumours) . .

I. Emphysema . .

II. Pneumothorax^ and various other conditions in
which the hyper-resonance is not the leading or
constant feature

(d) Diseases recognised by the Character of the Sputa :

I. Bronchiectasis
II. Gangrene of the lung

III. Abscess of thi lung

IV. Aetinomyoosis and other diseases due to fungi

§ 93

defined

§ 94
§ 95
§ 91]

§ 97
§ 98
§ 99
§ 100
§ 101
§ 54

§ 102

§ 89

§ 103

§ 104

§ 105

§ 105a

^ Pneumothorax sometimes comes on acutely, but it is more often part of a chronic
diflemw.

154 THE LUNQS AND PLEUR.E §§ 92, 98

§ 92. Method of Procedure. — ^The routine examination is conducted
as in acute disorders {§ 80) — viz., after ascertaining the leading symptom,
and the history of the ilhiess, we proceed to Inspection, Palpation, Per-
cussion, and Auscultation. In percussion, remember to keep the hand
flat and firmly pressed against the chest, while it is struck by one or more
fingers of the other hand, used as a hammer, and with a staccato stroke.
Remember also that the note is normally dull over the mammae in most
women, over the scapulae in muscular men, and that it is slightly lower-
pitched at the right than the left apex. The chest must, of course, be
stripped.

Groxtf a. — The patient's symptoms point to chronic disease of the longs,
and on examining the chest there is no alteration in the percussion note.

I. The patient has a chronic cough ; there is no elevation of temperature,
and on auscultation rhonchi and rales are heard over the chest. The
disease is Chronic BRONCHms.

§ 98. Chronic Bronchitis is a chronic inflammation of the bronchial tubes.
It may be chronic from the beginning, or it may supervene on repeated
attacks of the acute disorder.

Symptoms, — A patient with chronic bronchitis and — its usual sequel
— dilated right heart presents a tjrpical appearance. Stout in build, with
short, thick neck, of florid complexion, short of breath, wheezy respiration,
and pulsating jugular veins, he presents an aspect which can be recognised
at once. The clinical history extends over many years, with alternate
diminution and aggravation of the symptoms. The cough is usually
present during the winter, and improves as the weather gets warmer.
The constant coughing and straining to bring up the secretion results
sooner or later in generalised emphysema. In later stages the cough
continues all the year round, and finally an attack of capillary bronchitis,
oedema of the lung, or some intercurrent malady, throws a little extra
strain upon the overburdened right heart, and death ensues. There are,
as a rule, no febrile or constitutional sjnnptoms.

The Physical Signs vary with the amount of secretion present, the
amoimt of the complicating emphysema (§ 102), and bronchiectasis (§ 103).
In cases of long duration the chest is barrel-shaped (emphysematous,
§ 74). Rhonchial fremitus may be felt on palpation. On percussion there
is never any dulness, and the note is hyper-resonant in proportion to the
emphysema present. On auscultation sibilant and sonorous rhonchi and
bubbling rales can be heard ; and crepitations at the base, due to oedema,
may be present.

There are four recognised varieties of this disease : (i.) Bronchitis with
winter cough, attended by slight or abundant expectoration, mucous or
muco-purulent, sometimes fibrinous, sometimes containing streaks of
blood, (ii.) Dry Bronchitis is attended by a frequent cough and soreness
of the chest, but little or no secretion ; it is of a very obstinate character,
and occurs mostly in elderly people of a gouty diathesis, (iii.) Bron-

§ 9S ] CHRONIC BRONCHITIS 155

(^iorrhosa is recognised by the expectoration, which is of a thin, clear, or
thick and ropy nature, very abundant and devoid of air. (iv.) FcBtid
Bronchitis may occur in the later stages, and marks the onset of bron-
chiectasis. The sputum is very foetid from time to time (see Bronchiec-
tasis, § 103).

Tlie Diagnosis of chronic bronchitis is not usually difficult. It may be
readily diagnosed from chronic phthisis by the appearance of the patient,
by the absence of hectic fever and emaciation, and by the absence of the
tubercle bacillus from the sputum.

Etiology. — Chronic bronchitis may occur at any age, but is more common
in elderly people. Sometimes, as before stated, it follows repeated attacks
of acute bronchitis, but it may be chronic from the beginning. It often
affects plethoric subjects, especially those of a gouty habit, and it is one
of the recognised complications of Bright's disease. It is a frequent
sequel to cardiac valvtdar disease, more especially disease of the mitral
orifice. It may complicate other diseases of the lungs, especially phthisis,
and may be a sequel of the acute specific fevers, especially measles and
enteric fever.

Prognosis, — Patients with chronic bronchitis seldom entirely recover,
though they may live for a great many years ; and if the heart is fairly
healthy and care be taken to avoid exposure, life is not very materially
shortened. The coexistence of gout, Bright's disease, and cardio- vascular
degeneration make the prognosis somewhat less favourable. The con-
dition of the lungs is not so much a guide to prognosis as the condition of
the heart. This, indeed, is the point around which the progress centres,
and the untoward symptoms which render the prognosis grave are thus
referable to the heart — ^viz., considerable dilatation of the right heart
with evidences of cardiac failure, such as dropsy, rapid, irregular pulse,
great breathlessness, and cyanosis (see § 50).

Treatment. — The extreme frequency of the disorder renders the treat-
ment a matter of considerable importance. In severe cases the'^patient
must be confined to one room at a imiform temperature of 62° F. day and
night. When the mucous membrane is dry and irritable, a steam kettle
gives great relief ; it must be kept constantly going, not used intermit-
tently. In slight cases, however, the patient can go about, but chill and
exposure should be avoided. The important question of when a patient
may go out must depend largely on the weather — cold and moisture,
especially when in combination, are especially injurious.

The indications as to treatment are : (i.) To stimulate the relaxed
mucous membrane with such remedies as am. carb., senega, squills, etc.
(ii.) When the cough is dry, soothing remedies, such as bromides, codeia,
and tr. camph. co. should be given, or remedies directed to promote the
secretion, such as ipecac., ammon. chlor., potass, iod., and alkalies (the
last two especially in rheimiatic or gouty cases), may be employed, (iii.)
Wien the sputmn is very abundant, we should endeavour to diminish
secretion by such remedies as the balsams (tolu and peru), tar prepara-

166 THE LUNOa AND PLEVRM { § »Sn

ttons (cieoaote, guaiacol, petroleum), tuipeutine, camplior, senega, etc.,
given either intemall}' or in the fonn of inhalationB. For the latter, tar,
cj^osote, and tcrpbene may be used. Counter- irritants to the chest—
e.g.. turpentiue, camphor, or eiicalyptuB, are very popular n-ith some,
(iv.) When t.hero is much apasm of the tubes, lobelia, iodide, and other
remedies for asthma are to be tried, (v.) Cardiac tonics and stimulantA
are called for sooner or later where dyspncea and other cardiac symptoms
are present, (vi.) In cases with a gouty taint Ems water each morning,
and small doses of iodide may be added to the other treatment, and the
emuDcliiries may be aided by sipping hot water morning and evening,
and at intervals during the day.

S 9Sa. Ftiitlo BnmchitU is inflammation of tho bronchi, with the formation of
libTo-pUatio OBBts. which arc ospoctonted.

Symptom». — The symptoma consist of (i.) violent attacks of coughing, with ex-
piratory dyspnoea, followed by (ii.) the expectoration of a fibrinous cost of a bronohus
[vidt Fig. 46). (iii.) Tho patient geoenkUy suffers from
chtonio bronohitis, and a liltlo hiemoptysia may follow
the expulsion of a oast, (iv.) Somctimos there am no
constitutional symptomB, but slight pyrexia, and in
some cases oven rigors may bo present. Such symp-
toms auporvsning in a case of chronic bronchitiB load
us to siupoot tho condition.

Fhytieal Sign^ may bo absent. If present, thoy
aro those of an obstnictad bronchus — an absent or
diminished respiratory murmur, acoompanied possibly
by impaired percussion noto. WhistUng Aonobi or
" flapping " Boundfl may be heard.

CaKtet. — The disease is twice as common in men
as in women. It may oceur at any age in subjects of
chronic bronobitis.

Prognogig. — The condition is more serious than

bronchitis. Two varieties have been described :

(1) Ad acute form, lasting for some weeks ; and (2) a

Fis. <fl. — Brokchi*!, Cast. chronic form, occurring at intervals, for years, in tho

course of chronic bronchitis. Each attack may last

for some weeks, and the casta bo coughed up daily. The condition occasionally leads

up to a fatal iasae from dyspncea, as when a large cast cannot bo brought up.

The TreatmtiU differs but little from that of bronohitis. The removal of the
membrane may be promotod by the inhalation of Ume-watoc. atomised by means
of a spray, which in used with a view to dissolve the mucin in the oast. Various oils
(<.;., creosote oil, 1 in 40) have been injected as solvents, bnt the results have not
been very promising.

Group B. — We now turn to those chronic diseases of the lungs
which are accompanied by dnlnen on pereosrion. (a) The more common
diseases, in which the dulness occurs in regular and fairly defined arras
at base or apex, are : I. Chronic Pulmonary Tubehcui,o8is ; II. Hyiiro-
THORAX ; and III. Pulmonary Congestion or (Edrma.

I. The ■patient comjitaina of gradual emaciation and perhaps cough; on
examination of the chetl signs op consolidation may be found, most
marked at the apex of the lung ; there is intbbmittbnt PTBBXiA, and the
sputum may coTOain the tubercle bacillus. The disease is Chronic Pul-
monary TuBBRGULOSia {Phthtsis).

S 94 1 CHRONIC PULMONARY TUBERCULOSIS 157

§ 94. Ohrcmio Pnlmonary Taberoalosis (Phthisis) may be defiued as a
wasting disorder due to tuberculosis of the lungs. The word phthisis is
objectionable because it only indicates one of the symptoms — viz., the
wasting (<^^tV(D, to waste). In view of the fact that this disease is the chief
cause of death in Great Britain (483,321 in 1910), the importance of the
subject cannot be overestimated. The number of deaths in 1910 in London
alone was 5,555, or 1* 14 per 1,000 living. The disease was formerly regarded
as due to roimd, nodular growths, " tubercles," scattered throughout the
limgs, which are made up of a large number of small round cells, epithelioid
cells, and giant cells. Owing to the discoveries of Koch we now know
that these little nodules are only the inflammatory manifestations con-
sequent on the irritation of a bacillus (the tubercle bacillus), and that
the disease is primarily due to the ravages in the economy of this bacillus
and its toxic products, and secondarily, to the supervention of other infective
processes, and especially those due to pyogenic organisms invading the lungs.

It is customary to describe the anatomy in three stages. It is now
generally believed that tuberculosis of the limgs begins as a tuberculous
endo-bronchitis, due to the settling of the mircobe in one of the smaller
bronchial ramifications. It has been shown by Birch-Hirschfield, who
took metallic castings of the bronchial tubes, that the reason the microbe
settles at the apex is because in this situation there is, as it were, a ** dead
end," in which air is not so readily changed as in other situations. As
a consequence, any dusty particles containing the bacillus which are
inhaled and reach this situation, settle down, and there set up an irrita-
tion, resulting in a small localised ulceration of the mucous membrane.
This corresponds with the generally accepted teaching that pulmonary
tuberculosis is chiefly caused by the inhalation of tubercle bacilli. The
congestion which takes place around the primary foci constitutes (a) the
first stage. (6) In the second stage there is considerable cell proliferation
filling up the air cells and resulting in the formation of nodules consisting
of granulomatous material in the neighbourhood of the primary mischief.
This is the stage of consolidation, (c) The third stage is one of breaking
down. Owing to the indolent character and low vitality of the new cell
formation, it caseates and softens, becomes the seat of pyogenic organisms,
and destruction of the air cells and formation of smaller or larger cavities
results. Thus we have three stages : (a) Congestion ; (b) consolidation ;
and (c) breaking down, with the formation of cavities (Fig. 47).

Symptoms, — The disease is essentially a chronic one, and its onset is
very insidious. It is always more amenable to treatment in the early
stage, and since the introduction of modem methods of treatment an
early recognition of the disease has come to be of paramount importance.

(a) Prodromal Stage, — Phthisis has six modes of onset, which, in order
of frequency, are as follows : (i.) Progressive weakness, attended perhaps
by cough; (ii.) haemoptysis^; (iii.) dyspepsia; (iv.) laryngeal tubercu-

^ Elarly haemoptysis of a very profuse kind may occur before any physical signs arc
discoverable.

158 THE LUNOS AND PLBVRM (IM

loais ; (v.) dry pleurisy ; {vi.) acute paeumonia (g 87o), bronchitis, or
broncho- pneiunonia. Among the earlier general aymptomt which should
niake ua suspect the invasion of tubercle are unexplained debility, attended
by languor and antemia on the one hand ; or loss of weight, with unex-
plained dyspepsia, or slight elevations of temperature in the evening on
the other. The temperature is an indicatioii of the very greatest im-
portance, for no ACTIVE Ivberculoua process can take place in any port 0/
the body without the occurrence of some pyrexia, however slight. The type
of this pyrexia is equally distinctive, for it is of an inlermiUent character,
being normal in the morning, and raised in the afternoon or at night ; in
rare instances this is reversed. If we have any suspicion of tubercle, the
temperature should be taken every two hours, so that we may not miss
any slight access of temperature during the day. AJlbutt has pointed
out that a premenstrual elevation of temperature sometimes occurs. In
the early stage the patient may
not be aware of the feverishness,
III. L'oviutioa. though generally he feels a chilli-

ness in the evening, and as the
11. ConMiidutioD. disease progresses, night sweats

form one of its moat characteristic
I. Cangratlon. features.

The later symptoms of the
disease are largely due to the
action of organisms other than
the tubercle bacillus. The clinical
manifestations of these " mixed
infections" are not always
obvious, but many hold that
' PuLuoNARv whenever the temperature rises

Ml rOGETHKB ^-^^^^ jqq.^o ^^ jqjo p jj j^ j^^

to a superadded infection of this
kind. It adds considerably to the gravity of a caae, and its prevention,
by freah air, cleanliness, and a hygienic mode of life is important.

The Physical St^tu accompanying the prodromal stage are necessarily
somewhat vague and difficult to detect. The patient's chest should be
thoroughly stripped, and he should be taken to a room where perfect
quiet prevails ; and if with the above symptoms we find weak or harsh
breathing and prolonged respiration at one apex— especially if this is
accompanied by an occasional single sibilant rale— we may be fairly
certain that the disease is developing. Persistent inspiratory " sticky "
clicks at one apes are very suggestive, if not pathognomonic of early
phthisis. It is important to auscultate while the patient coughs, for
rales not previously audible may thus become evident. The signs just
named can often be heard best at the apex, behind, by placing the patient's
hand on his opposite shoulder and listening to that part of tiie lung, just
external to the bronchi, which will thus be Mncoivrerf by the scapula. Fine

194] OHBONIC PULMONARY TUBERCULOSIS 159

crepitations may be heard in that situation weeks before any signs can be
discovered at the apex in front. In front the earliest signs may be heard
just beneath the clavicle. Sometimes, later on, we are led to detect
phthisis by an imdue loudness of the heart sounds at the apex of one lung.
Absence of dulness, like the absence of bacilli, is not evidence of the
absence of tubercle. The sputum should be repeatedly examined for
tubercle bacilli. If primary disease of the upper air passages be excluded,
the presence of tubercle bacilli in the sputum is diagnostic of pulmonary
tuberculosis. The early morning sputum should be examined, as it is the
most likely to contain the bacilli. However, the absence of bacilli, even
after a series of examinations, does not indicate the absence of phthisis.

Other tests for the presence of tuberculosis are :

i.) In Morel' a test an ointment impregnated with tuberculin is rubbed into the
skin ; in tuberculous oases a papulo-pustular rash appears and lasts several days.

(it) In Yon Pirquet's cutaneous reaction the arm is lightly scarified, and a drop of
Koch*8 concentrated old tuberculin is rubbed on the scarified area. In a positive
reaction a red papule appears, occasionally after a few hours, usually within twenty-
four hours, but it may bo delayed oven longer. This test is valuable in children ;
in adolte 70 per cent, of apparently healthy persons react.

(iiL) In CalmeUe's ophthalmic reaction a drop of 1 per cent, of Koch's old tuberculin
is placed on the conjunctiva. This tost is not devoid of risk to the eye. If positive,
it indicates the presence of tubercle which may or may not bo active ; if negative, it
does not necessarily indicate that active tuberculosis is absent.

(iv.) In the subcutaneous tuberculin test Koch's old tuberculin is inoculated under
the skin in increasing doses — \ milligramme, 1 milligramme, 5 milligrammes, and
10 milligrammes. A positive reaction is shown by (1) a local reaction at the site of
inoculation, which is of no importance ; (2) subjective malaise and fovcr, and (3) re-
action at the site of the tuberculosis. Thus in pulmonary tuberculosis crepitations
and increased expectoration would occur. This test should never bo employed
when patients have fever or other obvious organic disease.

Dr. Inman ^ points out that none of these tests are of assistance in deciding whether
tuberculosis is active or dormant, and they arc valuable only as one of many factors
which have to be considered before advising lengthy courses of treatment.

(v.) A positive opsonic index test, however, points to the pro;jonco of active tubercu-
losis ; but a negative test does not disprove the existence of tuberculosis. The normal
opaonio index range is between 0*8 and 1*2. An abnormally high, or an abnormally
low, or a widely vaiying index, indicates the prosence of active tuberculosis.

(6) The 8t(ige of consolidation and (c) the stage of softening and cavita-
tion may be dealt with together. The symptoms, physical signs, and
the corresponding limg changes are given in the form of a table for the
purposes of convenience. The physical signs usually begin at the apex,
and are generally best heard at the back, sometimes at the apex of the
lower lobe. From this position they extend downwards, and thus it is
possible in the same patient to recognise in advanced cases the signs of
the third stage, or cavitation, at the apex ; below these, signs of consolida-
tion ; and below these, signs of congestion (as in Fig. 47). Such a con-
dition indicates considerable activity. Many accessory signs may be
mentioned : enlarged heart area due to retracted lung, hsemic heart
murmurs due to anaemia, clubbed Engers in chronic cases of long duration,
etc. Extensive tuberculous disease may sometimes exist with but little

^ Inman, the Lancet, December 17, 1910.

THE LUN08 AND PLEURJE

[§M

constitutional disturbance, and on the other hand, considerable disturb-
ance of health may be present, without any abnormal physical signs —
depending, partly, on the distance of the lesion from the surface of the
lung.

Table VITT. — Three Stages of PHTHI^^Is.

Anatomy,
(Ste Fig. 47, p. 158.)

Physical Signs.

Symptoms.

(a) CoKGKSTi024of lung j At apex of the lung —

tissue, consequent
on invasion by
tubercle bacilli.

(b) Consolidation —
due to the hyper-
plasia, cell infil-
tration, and the
fusing together of
the tuberculous
foci.

(i.) Feeble R.M., with oc-
casional fine crepita-
tion heard at end of
inspiration ; or
(ii.) Unduly harsh breath-
ing with a pro-
longed expiration.

Over diseased part, usu-
ally at apex, are :
(i.) Impaired movement ;
(ii.) Flattening ;
(iii.) Increased vocal fremi-
tus ;
(iv.) Bull percussion note ;
(v.) Bronchial or tubular

breathing ;
(vi.) Bronchophony (in-
creased V.R.).

Signs as in (6). plus —

1. Moist clicking rales ;
and later on —

2. Signs of presence of

cavity :
(i.) Cavernous

breathing,
(ii.) Post-tussic suc-
tion ;
(iii.) Pectoriloquy ;
(iv.) Rdles with me-
tallic tinkle.

(i.) Increasing languor on
exertion ;

(ii.) Slight morning cough ;

(iii.) Slight rise of tempera-
ture ;

(iv.) In some cases htemop-
tysis.

(i.) Weakness and emacia-
tion increase ;

(ii.) Temperature markedly
higher in the even-
ing ;

(iii.) Night sweats ;

(iv.) Anaemia.

All the above 83rmptoms

aggravated :
(i) Cough distressing, with
quantities of num-
mular expectora-
tion; haemoptysis
may bo profuse ;

(ii.) Temperature high, and
with wide range ;

(iii.) Sometimes diarrhuea,
etc.

The presence or absence of a cavity is in the majority of cases impossible to
diagnose with certainty. The percussion note is usually dull, but varies with cir-
cumstances. Thus the note is resonant when (i.) the cavity is largo, or lies very
superficially ; and (ii.) there is not a great amount of consolidated lung tissue between
the cavity and the chest wall. When the cavity is large and superficial, and the
communicating bronchiis remains patent, a characteristic note, almost tympanitic »
is obtained on percussion whilst the patient keeps his mouth open. This is known
as the ** cracked-pot " sound (bruit de pot fele). Many attribute most importance
to the sign known as ** post-tussic suction.*' To elicit this sign, the stethosoope is
applied over the suspected cavity, the patient is told to cough, and immediately
after the cough a characteristic swishing sound is heard, duo to the sucking of air into
the cavity. This may be accompanied by copious rales.

{94] CHRONIC PULMONARY TUBERCULOSIS 101

The Diagnosis of the disease is not difficult except in the early stages,
and in the absence of bacilli in the sputum, (i.) Various other causes of
hsemoptysis may have to be differentiated (see § 7t)) ; (ii.) various other
causes of anaemia may have to be eliminated (Chapter XVI.) ; (iii.) when
the condition begins with dyspepsia, it is very liable to be overlooked
unless the physician is aware of this mode of commencement ; (iv.) other
causes of cough (§ 70) ; and (v.) various laryngeal affections may have
to be excluded (§ 119). (vi.) When it supervenes on bronchitis or broncho-
pneumonia, our only clue consists in a delayed convalescence, together
with the persistence of rales ; and the fine clicking rales of phthisis are
quite distinctive to the experienced ear. In the later stages of the disease
the differentiation from the other cases of percussion dulness is not difficult
(table, § 91).

Etiology, — In phthisis, as in other microbic disorders, there are, on the
one hand, predisposing causes which relate to the patient (i.e., the soil
on which the bacillus grows) and his powers of resistance ; and on the
other hand, exciting causes which relate to the microbe itself. If the
" soil " is not suitable — i.e., if the person is not predisposed by heredity
or other cause, the bacillus will rarely grow. For these reasons its in-
fectivity has been overlooked all these years. (1) Heredity is a potent
cause, the individual being bom with a predisposition to the disease.
This factor, however, does not, as we shall see, occupy the prominent
position which it was formerly believed to occupy. In a large proportion
of cases no evidence of heredity is obtainable. (2) Both sexes are pretty
equally affected, and the favourite age at which the disease usually super-
venes is between twenty and thirty. The patient may be attacked at
any time of life, although it is very rare under two years. (3) Any con-
dition of malnutrition may produce a predisposition to the bacillus invasion,
whether it arise from deficient food, from hyper-lactation, from exhausting
diseases such as diabetes, or the acute specific fevers, after which an
attack of phthisis is by no means infrequent. It is a curious circumstance
that pregnant women are not prone to the disorder, and a phthisical
subject becoming pregnant will often improve until after her confinement,
when an exacerbation of the disease will occur, which has usually a fatal
result. (4) Unhealthy surroundings play a most important part in the
production of phthisis, and indoor occupations such as those of lace-
makers and city clerks are specially unfavourable. A damp soil un-
doubtedly favours the production of the disease — even the dampness
from faulty construction of a dwelling will do so. A moist, hot atmo-
sphere, such as exists in certain factories, favours the spread of the disease.
A dust-laden atmosphere, such as that of stonemasons, knife-grinders,
tin and copper miners, fustian-cutters, is a potent cause of phthisis. (5)
The recent report (1911) of the Royal Commission on Tuberculosis con-
firms the view that tuberculosis in mankind is due to two types of tubercle
bacillus, one of human and one of bovine origin. Pulmonary tuberculosis
is usually due to infection by the human bacillus, which is conveyed by

162 THE LUNGS AND PLEURM [ § 94

air tainted with dried sputum containing living bacilli — hence the im-
portance of destruction of the sputum. In children, on the other hand,
the bacillus is usually of bovine origin, and it is found chiefly in the
abdomen (peritoneum or glands), joints, cervical glands, and in the lungs
when acute miliary tuberculosis carries the bacillus from an infected focus
to the blood-stream. The bovine bacillus apparently enters the body
via the alimentary canal, and therefore it may be concluded that the
disease is due to the ingestion of infected milk or other products of tuber-
culous animals. It is, however, an undoubted fact that mankind is
naturally resistant to the tubercle bacillus. Birch-Hirschfield undertook
a laborious investigation of 4,000 post-mortems, and he foimd that in
40 per cent, of these persons, dying from all manner of diseases, the lungs
showed evidences of tubercle which had imdergone spontaneous recovery.
In view of these facts, and that most of the predisposing causes above
mentioned are preventable, there is no reason why phthisis should not
one day become as rare in England as leprosy is to-day.

Prognosis, — 1. Usual course and duration. Phthisis is essentially a
chronic but progressive disorder, and until recently nearly all cases apply-
ing for treatment terminated fatally. The death-rate from phthisis in
1838 was 38 per 1,000; in 1892, 14 per 1,000 living; and in 1910
13-4 per 1,000 living. Rapid cases may terminate in death in the course
of three to six months. When the disease is indolent, and the patient
resistant to the microbe, it may drag on for years. There are four
chief modes of death, which in order of frequency are — (1) asthenia,
(2) hemoptysis, (3) asphyxia from pneumothorax, (4) the occurrence of
other complications.

2. The prognosis in reference to Causation, depends on : (i.) Heredity.
Unquestionably it takes a more favourable course and the process tends
to be less active in cases where there is no family history of tuberculosis,
(ii.) The age of the patient influences the course considerably, for it is
much more rapid in the young than in people over thirty, (iii.) The
hygienic surroimdings of a patient, as we shall see under treatment,
make considerable difierence to the course of the disease. Where the
patient is well-to-do and can be removed from those conditions which
have promoted the disease, he has a good chance nowadays of recovery ;
but among the poor, who are forced to continue among their squalid
surroundings and at their work, a fatal issue almost necessarily results,
(iv.) Previous alcoholic excess diminishes the chance of recovery.

3. Untoward Symptoms. — (i.) Undoubtedly the most important feature
is the temperature. Not only is an active tuberculosis evidenced by
pyrexia, but the degree of fever, and still more the extent of the variations,
are a fairly precise measure of the activity of the tuberculous process,
(ii.) The condition of the lung is of course important. The presence of
rales, as denoting softening and advancing disease, is unfavourable ; and
their disappearance favourable, but the extent of lung involved is as
important a factor in prognosis. Thus, a man in the third stage, with

S 94 ] CHRONIC PULMONARY TUBERCULOSIS 163

a cavity at the apex in one lung, and little disease elsewhere, has a better
chance of recovery than one with slight tuberculous foci scattered through
the lung. If both lungs show disease in the third stage, recovery is rare,
though health has been restored in some cases after prolonged treatment,
(iii.) The general symptoms also aid us in recognising the rate of progress.
When the weight is increasing, the temperature declining, and food is
taken well, the chances of recovery are good, (iv.) Early haemoptysis
does not affect the prognosis in any way, but occurring later in any
quantity is apt to weaken the patient considerably.

4. Complications. — The presence of complications is undoubtedly bad.
The commonest complications are : (1) Pleurisy, which is very frequent,
but is often of a conservative nature, for adhesions may sometimes pre-
vent pneumothorax ; (2) tubercle may occur in other parts — the peri-
toneum, meninges, and especially in the intestine, giving rise to ulcera-
tion and an exhausting diarrhoea ^ ; (3) the larynx may be affected either
previously or subsequently, and imdoubtedly it adversely influences the
prognosis ; (4) lardaceous disease of the liver, spleen, and other organs
used to be frequently seen ; (5) pneumothorax and pyopneumothorax may
ensue from the bursting of a cavity into the pleura — fatal asphyxia may
result (§ 89) ; (6) thrombosis of various veins is a less common complica-
tion; (7) peripheral neuritis is now a recognised occurrence, sometimes
very early in the disease ; (8) vomiting.

It is a good rule never to commit yourself to an opinion on any case
of phthisis without first noting the effects of treatment.

Treatment of Phthisis. — The subject of treatment will be dealt with
under four headings : (a) remedial ; (b) symptomatic treatment ; (c) treat-
ment by tuberculin; (d) the open-air treatment; and (e) preventive
measures. The indications of all treatment are to reduce the inflammation,
to destroy the virus, to build up the strength, and to palliate the symptoms.

(a) The Remedial Treatment formerly in vogue was mainly directed to
building up the strength by means of cod-liver oil, maltine, hypophos-
phites, and other tonics. Cod-liver oil is of great value in treating afebrile
cases. Guaiacol, 20 grains (gradually increased), creosote, eucalyptus
and other antiseptics may be given at any time. Thiocol (gr. v.) thrice
daily has all the advantages, without the drawbacks, of creosote. By
some these are also administered as an injection into the lung. Perhaps
the best of this kind of treatment is the use of a spray four times a day,
lasting fifteen minutes, of formalin.^ Inhalation of antiseptics may be
administered by Yeo's respirator. Counter-irritants were largely used
to reduce the inflammation, the favourites being iodine or croton oil
applied over the apex of the lung. These measures were supplemented
in wealthier patients by sea-voyages, high, dry moimtain air, and residence

^ BiarrhoBa may also occur as part of the hectic fever without any ulceration of the
bowels.

^ Dr. Lardner Green recommends the following formula (Formalin =40 per cent, of
Formic Aldehyde) : Formalin, 5i« ; Glycerine, 3iv. ; Aq. Dest, 5v. Use as spray four
times a day, fifteen minutes at each inhalation {Lancet, August 19, 1899, p. 521).

HA THE LVNQS AND PLEVBM \ § 94

abroad during the winter, combined with a liberal dietary and generaj
hygienic mode of life.^ These various methods are still useful, but at
the present time we have other powerful means of combating this lethal
disease. It has been noted in some cases that the supervention of
pneumothorax, if not very quickly fatal, often leads to a considerable
improvement, and therefore the induction of artificial pneumothorax 2
has been tried as a therapeutic measure. From 250 to 500 c.c. or more
of nitrogen are introduced into the pleural cavity through a syringe.
The lung collapses and is thus put at rest until the nitrogen is absorbed.
It may be necessary to repeat the injection more than once. The method
is only suitable where one lung is almost free from disease. In some
cases the results have been extremely favourable and the operation in
experienced hands is not dangerous.

(h) Symptomatic Treatment. — It will be seen that in the third stage
there is not much hope of recovery, but even in the worst cases we can
ameliorate the symptoms, and so ease the passage to the grave. (1) For
the cough, tinct. camph. co. and other expectorants are not of much use.
The best cough mixture is one containing liquor morphine, or, better
still, codeia in small doses with dilute sulphuric acid. Wcum alkaline drinks
promote expectoration. (2) Night sweats, which are often very profuse
and exhausting, may be combated by atropine, zinc oxide, picrotoxin,
and strychnine, especially the first named. Night sweats are said to be
seldom troublesome if there be free exposure to fresh air. (3) The diar-
rhoea is also very exhausting, and must be combated with catechu, opium,
intestinal disinfectants, and mineral acids. (4) Pleuritic pains may be
eased by stupes, or painting with tincture of iodine. (5) The concurrent
dyspepsia must be combated in the usual way, but the vomiting is often
a very troublesome symptom, and there are three kinds of vomiting which
admit of three different methods of treatment, (a) If preceded by nausea,
it points to disorder of the stomach, and should be treated by bismuth,
etc., on the usual lines, (b) If the vomiting be preceded and caused by
coughing, it is a good plan to give hot drinks just before a meal, in order
to encourage the expectoration and get the paroxysms of coughing over
before the meal is commenced, (c) If neither of these causes can be
traced, the vomiting is probably due to irritation of the vagus, and may
sometimes be relieved by opium. Sometimes vomiting is controlled by
the will. (6) The treatment of haemoptysis, pneumothorax, and laryngeal
ulceration are dealt with elsewhere.

(c) Treatmsnt by Tubercvlin depends upon the principle of immunisa-
tion (§ 386). Koch followed his discovery of the tubercle bacillus by

^ Simple respiratory exercises, such as the following, designed to expand the chest,
form a useful adjunct : (i.) With the back against the wall, fully extend the arms to tho
level of the shoulders slowly for eight times, (ii.) Continue the same movements until
the arms meet above the head, (iii.) Start with the hands above and in front of tho
lioad, and bring them slowly down until the backs of tho hands meet behind the body,
at the level of the buttocks, the arms being rigid all tho while. These should be done
twice daily, gradually increased to five to six times daily.

* Colebrook, the liwcei, 1911.

§94] CHRONIC PULMONARY TUBERCULOSIS 105

soon afterwards issuing to the world the toxin produced by the bacillus.
This he called tuberculin, and it is now called oil tuberculin. It was
administered hypodermically and produced considerable " reaction " —
i.e., constitutional disturbance — in the patient. It was largely used, but
the results were not satisfactory. There are now several tuberculins on
the market. The initial hypodermic dose (sttVif ^g-) ^ gradually increased
imtil the patient can tolerate larger doses without any rise of temperature
or excessive local reaction. If either local or general reaction occurs,
the dose is diminished and the interval between the doses is increased.
Some hold that tuberculin should not be administered except by those
who are conversant with the methods of control by measurement of the
opsonic index. Others report good results from large doses. Dr. Nathan
Raw^ finds that small doses of bovine tuberculin give good results in
pulmonary tuberculosis.

(d) The " open-air,^^ hygienic, or sanatorium treatment of phthisis, as
it is now called, is not altogether a new method, for fresh air has always
been advocated as advantageous to these patients. Systematic open-air
treatment was first established at Nordrach. There are now numerous
sanatoria both at home and abroad. Much discussion has taken place
as to whether the treatment cannot be carried out without a sanatorium.
Among the well-to-do, perhaps, a sanatorium is not indispensable, but in
the middle and lower classes the necessary discipline cannot be otherwise
carried out. That residence in a sanatorium is not absolutely necessary
is evidenced by cases which have been under my care, even in an advanced
stage of phthisis, who were unable to go away. One of them spent all
the daytime in Kensington Gardens, in all weathers, and when indoors
the windows were always open. This patient recovered in six months.^

Briefly, the advantages gained by this method of treatment consist of.
(i.) Increased medical supervision from day to day and hour to hour by
the medical officer of the sanatorium ; (ii.) the continuous exposure of
the patient to fresh, pure air, night and day, the windows never being shut
and sometimes wholly removed ; (iii.) systematic exercise in suitable cases ;
(iv.) the ingestion of a large amount of suitable food ; (v.) a suitable
amount of rest during the fever stage, and a freedom from excitement ;
(vi.) the avoidance of mixed infections by hygienic mode of life. Cleanli-
ness and fresh air tend to obviate pyogenic processes and infections.
All possibility of the introduction of influenza and other infective dis-
orders should be avoided by the proper regulation of visitors to patients.
I believe that some day these latter will be subjected to the most rigorous
scrutiny and inquiry before being allowed to come in contact with the
consumptive patients in a sanatorium. The mixed or superadded in-
fections do more harm than the tubercle bacillus. This is probably the
reason why tuberculous patients do so badly in the wards of a general
hospital. The treatment varies at the different sanatoria. In some,

1 The 2>znce^ April 8, 1911.

^ See also a case reported in the Lancet, January 20, 1900.

166 THE LUNGS AND PLEURM [ § 94

graduated labour is the chief feature ; in some the high altitude ; in others
tuberculin injections form important factors in the treatment. Patients
who return to ordinary life, return with a working knowledge of the
hygienic rules appropriate for consumptive subjects.

The possible disadvantages ujged are : (i.) The fear of hyper-medication
that may go on in sanatoria ; and (ii.) certain unsuitable cases (see below)
may be deleteriously affected.

In carrying out sanatorium treatment, seven rules should be observed :

(1) Much depends on the suitability of the case, and the earlier the stage
the better. There are three conditions in which the sanatorium, or open-
air treatment, is imdesirable : (i.) When the process is too active, as
evidenced by a high and wide range of temperature^ ; (ii.) when the lungs
are too far destroyed; and (iii.) when the case is attended by active
bronchial catarrh.

(2) The food must be abundant, and the cuisine appetising and attrac-
tive .2 But here an important caution comes in, else the patient puts on
fat without influencing the disease. The food must be in proportion to
the exercise, and the patient's weight should never much exceed his
previously normal weight. The proteid food should be increased relatively
to the farinaceous, otherwise the patient becomes plethoric and breathless.

(3) Evidences of benefit should be carefully looked for. They are three
in number : (i.) A lowering of the temperature and a lessening of its range ;
(ii.) an increase in the appetite ; (iii.) increase of weight combined with the
two previous features.

(4) In deciding the important question of rest or exercise, the great
value of accurate temperature records is again seen. The system of
graduated labour introduced at Frimley Sanatorium by Dr. Paterson^ is
being followed by many with excellent results. There are six grades of
labour, varying from walking exercise, carrying heavy implements, to
the full work of a navvy. The patient is not allowed to begin work until
the temperature is stable at not over 99° F. in males, and 99' 6° F. in
females. If it rises after slight exercise, the patient rests until it is normal.
Progressively heavier work can be performed without any rise of tempera-
ture. The normal and mental effects are invigorating and enable the
patient to resume ordinary occupation after leaving the sanatorium with
a healthier standpoint than after a long rest with idleness.

(5) Amusement is necessary, but it requires to be carefully regulated.

^ Some do not regard this as a contra-indication to open-air treatment ; but in such
cases the length of the journey has to be considered, and the undesirability of mixing
such patients with others.

^ Thirteen pints of milk, or its equivalent, is in most institutions adopted as a fair
standard of diet ; that is, 9 ounces of proteid, TJ ounces of fat, 10 J ounces of carbohy-
drate : total, 27J ounces water-free food. With ** Parkes* Hygiene " percentage com-
position tables, varying diets can easily be made up containing the above proportion
of food elements.

^ "Auto-inoculation in Pulmonary Tuberculosis," by Marcus Paterson, 1911.
The continual auto-inoculation induced by exercise sets in motion the protective
mechanism of the blood.

S94] CHRONIC PULMONARY TUBERCULOSIS 167

The patient should not talk too much, and any excitement or heated
discussion is bad. The whole day, and, ifjoossible, the night also, should be
spent out of doors, no matter what the weather may he, and outdoor
amusement cultivated. A very useful contrivance is a small revolving
summerhouse, the front of which is open, and can be turned away from
the wind.

(6) The duration of the treatment must be sufficient, and should be
continued for some time after all symptoms have disappeared. If the
case is only in the first stage, cure may be accomplished in six months.

(7) The hygiene and the locality of the building are important matters,
but the reader must refer to special works for this. The beneficial effect
of mountain air has been proved beyond dispute. It is particularly in-
dicated in cases of consolidation without cavitation, but later stages also
can be benefited. Deeper, longer, and more complete respirations are
taken at high altitudes, and the air is purer than elsewhere.

(e) Preventive Treatment. — Since the microbic origin of tuberculosis was
admitted, the question of how far it is a contagious disease has been
keenly debated. The results of the labours of the Royal Commission are
mentioned above (p. 161), and from these conclusions it is obvious that
preventive measures come imder the headings of (1) prevention of the
communication of the disease from man to man ; (2) prevention of its
extension from animals to man; and (3) education of the public. (1)
Prevention of infection from man to man is ensured by destruction of
the microbe, and by strengthening the resisting powers of those heredi-
tarily predisposed to the disease. For the destruction of the microbe
the rooms in which phthisical people have lived must be thoroughly
disinfected ; and the sputum must be destroyed before it dries. The
patient must spit only into some portable receptacle containing a dis-
infectant such as lysol, or into paper sputum cups which can be burned.
Tuberculous patients should not share the sleeping rooms of healthy
individuals. (2) The method of prevention of infection from animals is
a matter for the consideration of the State. Bovine tubercle is conveyed
by the ingestion of the flesh or products of diseased cattle. In order to
protect the community from this danger it is necessary to have adequate
inspection and full powers of dealing with infected meat and milk. (3)
There are many ways of educating the public on the hygiene of the home
in tuberculous families. Tuberculosis exhibitions, lectures, etc., merit
the support of every medical man. The most practical scheme at present,
however, is the multiplication of tuberculin dispensaries. Sanatoria,
hospitals, and dispensaries ought to work in association. At the dis-
pensaries the early cases of tuberculosis are detected and drafted off to
sanatoria ; the homes of the invalids are visited and the inmates are
instructed as to the correct hygienic measures to adopt in order to pre-
vent contamination of those uninfected persons who have been in contact
with the disease. Treatment is also given at the dispensaries, but their
greatest sphere of usefulness lies in their educative influence.

168 THE LUNGS AND PLEUBJB [ H 94a. 95

f 94a. Fibroid Phthisis is one of the least oommon of the yarieties of pulmonaiy
tuberculosis. It may be defined as a tuberoulo-fibroid disease of the lungs, occurring
for the most part in elderly subjects, running a protracted course, and terminating
in contraction of the lung. This disease is very apt to be confused with chronic
interstitial pneumonia or cirrhosis of the lung (§ 97).^

Symptoma. — The dineaEe is essentially one of insidious onset and long duration.
The patient complains of a chronic cough for many years. Later on this may become
paroxysmal, and especially troublesome in the morning. Progressive shortness of
breath, clubbed fingers, slowly increasing weakness and emaciation, with little or no
fever, constitute the other symptoms.

The Physical Signs begin and are almost always most marked at the apex. Both
lungs are usually affected (which contrasts with interstitial pneumonia), but the signs
of disease are afterwards more advanced on one side. There is impairment of the
chest movement, and later on contraction of one side of the chest. The area of
prsecordial dulness is increased when the left lung is involved ; and the heart and other
viscera may be displaced. The signs of consolidation, with gradual softening, may
also be present. Hemoptysis sometimes occurs, and the tubercle bacillus may be
discovered on careful and repeated examination of the sputum.

The Diagnosis from other forms of phthisis is made by the extremely protracted
course of this disease and the age of the patient. Chronic interstitial pneumonia
resembles it very closely, both in its physical signs and symptoms, and the diagnosis
of interstitial pneumonia can only be inferred (i.) from the absence of the tubercle
bacillus after oft- repeated examinations, and (ii.) from the more usual localisation
in one lung.

Etiology. — Fibroid phthisis is more frequently met with at and after middle life.
It may follow chronic bronchitis, broncho-pneumonia, or repeated attacks of pleurisy.
In true Fibroid Phthisis the tubercle bacillus is primarily deposited in a healthy lung
under the same circumstances as in chronic pulmonary tuberculosis, and then causes
an indolent fibroid reaction. On the other hand, chronic interstitial pneumonia
may become the seat of tuberculous invasion, and in that case the causes of chronic
interstitial pneumonia are the causes of fibroid phthisis (see Interstitial Pneumonia,
S 97).

Prognosis. — Its couree is very indefinite and protracted. Sometimes acute tuber-
culosis supervenes. The chief complications are bronchiectasis, compensatory
emphysema of the lungs, lardaceous disease of other oi^ns, and cardiac failure. In
general terms the prognosis depends upon the same conditions as those of pulmonary
tuberculosis and the Treatment is the same.

II. The jxUient complains of breathlessness ; on examining the chesty dul-
ness is found at one or both bases, and signs of fluid are detected there.
The disease is Hydrothorax.

§ 95. Hydrothorax is a chronic collection of serous fluid in the pleural cavity,
differing from the effusion of pleurisy in being non-inflammatory.

Symptoms. — The general symptoms may be but little marked if the fluid is small
in quantity. The onset is usually gradual. Dyspnoea is generally present, especially
on exercise, but its degree depends upon the amount of fluid. As hydrothorax is
always a secondary condition, the symptoms may be masked by the presence of dropsy
elsewhere ; and it is remarkable how often hydrc thorax is overlooked on this account.
In rare cases the fluid collects with great rapidity.

The Physical Signs are those of fluid in the chtst {vide § 77). The level of the
fluid in hydrothorax, imless excessive in quantity, moves when the patient alters
his position, thus differing from the inflammatory fluid of acute pleurisy. This
is an important diagnostic feature which can always be elicited, except when the fluid
is confined by adhesions.

Diagnosis. — The disease has to be diagnosed from other disorders giving rise to
dulness on percussion (p. 153). As regards pleurisy, in addition to the mobility of

^ Reference to chronic interstitial pneumonia (§ 97) will show to what condition the
term ** fibroid phthisis " should be confined

S 96 ] HYDROTHORAX— (EDEMA OF THE LUNG 169

tho fluid, hydrothorax is distinguished by the absence of pyrexia at the onset, by the
abeence of pain, and by the fact that the fluid occurs usually on both sides.

Etiology. — (i.) Hydrothorax may form part of tho general dropsy of Bright*s disease,
in which circumstances both pleurae are involved. Here tho hydrothorax is of no
very great importance per se, but the onset of dyspnooa in Bright's disease should
always direct our attention to tho plourae. (ii) Similarly, it may form part of cardiac
dropsy, in which circumstances one pleura is often solely or chiefly affected, (iii. ) New
growths in the chost are generally attended by hydrothorax. This is especially so
in tho case of carcinoma, which should always be suspected in the aged. In this
case the fluid is blood-stained, and may be found to contain cancer cells. In tubercle
there is rarely much fluid in the pleura, adhesions being more common, (i v. ) Aneurysm
or other intrathoracic tumours pressing on the veins of the thorax may give rise to
hydrothorax on one or both sides.

Prognosis. — The disease is essentially chronic, the duration depending very much
upon the causa In general terms the prognosis of the condition is unfavourable.
Ihe patient should be carefully watched for tho occurrence of shivering, sweating,
or intermitting pyrexia, as indicative of empyema. The sudden onset of signs of
fluid in the chest, accompanied by shock or collapse, in a case which has previously
presented tho symptoms of aneurysm, points to the occurrence of hsemorrhage into
the pleural cavity (hsemothorax).

Treaimeni. — ^The treatment is comparatively simple. Tho administration of brisk
hydragogue purgatives will generally reduce the amount of fluid ; if this fails, or if
the fluid return, or in any case where dyspnoea is extreme, paracentesis (§ 85) should
bo resorted to. The operation of tapping may bo repeated indoflnitely. Diuretics
or cardiac stimulants are useful. For the rest, the treatment must be diroctod to
tho primary condition (see also § 85).

III. The patient complains of breatMessne^s ; on examining the chest, dulness, usually
slight, is found at one or both bases, and on auscultation, fine crepitations are heard.
The disease is Pulmonary Congestion or (Edema.

§ 96. CBdema of the Long (Pulmonary Congestion). — CEdema of the lung is a
serous exudation into and around the air vesicles. It is synonymous with the term
"hypostatic congestion,' or, as it is sometimes called, "hypostatic pneumonia"
It determines the end of many serious disorders.

Symptoms. — (i.) It is never a primary condition, and therefore our attention is
first directed to the symptoms of its cause. The advent of hypostatic congestion
is always insidious, and it is only by careful watching that it can bo detected,
(ii.) A considerable amount of dyspnoea is present, which may amount to orthopnoea.
(iii.) There is a frothy mucous expectoration, not infrequently tinged with blood.

The Physical Signs are somewhat indefinite, but they are found, as is implied by
the term " hypostatic," chiefly at the bases of both lungs. The percussion note is
somewhat impaired, and the air entry at the bases is diminished, and is attended
by abundant moist crepitations.

Ditignosis. — ^Tho condition is diagnosed from true pneumonia by the gradual onset,
the indefinite signs, and the absence, for tho most part, of pyrexia and other con-
stitutional symptoms. Any rise of temperature that may be present is duo to the
primary or causal condition.

Etiology. — (i.) The disease is most frequently mot with in elderly peoplo. (ii.) Pul-
monary oedema complicates various blood disorders and fevers, especially typhus
and typhoid fevers. The latter, indeed, is so frequently complicated in this way
that hypostatic congestion is an aid to tho diagnosis in tho second and third weeks
of tho disease. In Bright's disease and anaemia, oedema of tho lungs occurs as part
of a generalised dropsy, (iii.) Cardiac and other diseases, loading to mechanical
dropsy, produce oedema of the lungs, (iv.) Tumours pressing on the veins within the
mediastinum may result in pulmonary oedema.

Prognosis. — ^The prognosis is always grave, because pulmonary oedema indicates
either considerable impediment to tho circulation in the lung?, or a serious toxic
condition of the blood. It frequently terminates life in circulatory disorders, and
in specific fevers of the asthenic type. In pneumonia it heralds a fatal issue. The
extent of the oedema is indicated very fairly by the degree o' dyspnoea.

no THE LUNGS AND PLEURA [ f 97

TrtatmenL — ^The indications are to rolieve the cause, if possible, and to stimulate
the heart. Ammonium carbonate and other stimulating expectorants aid the heart
and promote expectoration. The liberal administration of alcohol and other
diffusible stimulants is called for. In the aged, among whom even slight disorders
are apt to be attended by pulmonary oddema, it is well to keep the paiient propped up
in a somi-recumbent posture. For the same reason it is advisable, in cases of fracture
and other surgical maladies in the aged, to get them up as soon as possible, even at
the risk of doing harm to their surgical ailment, so as to obviate the occurronce of
hypostatic congestion of the lungs.

Group B. — We now turn to the rarer chronic diseases attended by dnlness
on "percussion, in which the dulness occurs in irregular and scattered areas :
IV. Interstitial Pneumonia ; V. Thickened Pleura ; VI. Cancer
AND Other Tumours ; VII. Collapse ; VIII. Syphilitic Disease ; and
IX. Mediastinal Tumours.

f 97. Chronic Intentitial Pnenmonia — apart from that form due to the malign
effects of certain trades — is a rare disease. It may be defined as a chronic inter-
stitial fibrosis of the lung, localised or diffuse, according to the variety, running a
protracted course, and resulting in contraction of the pulmonary tissue.

An increase of the fibrous tissue of the lung may take place under the following
conditions, all being chronic processes :

(i.) An indolent tuberculous process may assume a fibroid character. Fibrosis
is one of the ordinary terminations of a tuberculous focus ; but when the progress
is very slow and protracted, with excessive formation of fibrous tissue, it constitutes
true fibroid phthisis,

(ii.) The constant inhalation of dust in certain trades {e.g., fustian cutters, jute
workers, wool-sorters, stone, knife, and other grinders and polishers, iron and coal
miners, etc.) gives rise to a chronic hroncho-prteumonia, followed by a peribronchial
fibrosis, which later on involves considerable areas of lung tissue.

(iii.) Repeated attacks of pleurisy may be attended by a subpleural fibrosis
(thickened pleura), and dense bands of fibrous tissue may extend into the lung (Sir
Andrew Clark).

(iv.) Acute broncho-pneumonia, becoming chronic, may, although very rarely, result
in an interstitial fibrosis. This form very often terminates by becoming tuberculous.

(v.) An acvie lobar pneumonia, similarly, may assume a chronic course, and may
result in an interstitial fibrosis (Addison). TMs form has not the same tendency
to become tuberculous.

(vi) Syphilitic disease of the lung is rare, except as a congenital manifestation in
infancy, in which circumstances the change consists of a fibroid induration of the
lung (Kingston Fowler).

All these may become the seat of tuberculous disease, but only the first, which
is a tuberctdo-fibroid process, should bo called " fibroid phthisis.'* The other varieties
constitute cirrhosis of the lung, and if they are invaded by the tubercle bacillus, they
form a fibro-tuberculous process, which in its later stages may be indistinguishable
from fibroid phthisis.

The general Symptoms consist of progressive weakness and dyspncea. There is
no fever unless there is ulceration of the bronchi or septicaemia — a common occur-
ronce in late stages of the disease.

The Physical Signs may be found either at the base or the apex, though usually
the former. Except in the variety due to the inhalation of irritating particles, only
one lung is involved, thus differing from fibroid phthisis, in which both lungs are usually
affected. There is deficient mobility of the diseased side, which later on undergoes
contraction, so that there may be considerable difference in the measurement of the
two sides of the chest. There is dulness on percussion. On auscultation, bubbling
rales may be hoard, but sometimes the only symptom is weak bronchial breathing
or a weak respiratory murmur. The expectoration sometimes contains blood, but
never the tubercle bacillus.

SI 98, 09] MALIGNANT DISEASE OF THE LUNG 171

The Diagnoaia of interstitial pnoumonia from fibroid phthisis is sometimes very
difficult, as may bo soea in the description of the yarious piooesses just named. It
is also liable to be mistaken for empyema.

The Etiology of the condition is given above. It is met with chiefly in male subjects
undor the age of fifty — especially between fifteen and thirty. Alcoholism predisposes.
The commonest form of chronic interstitial pneumonia is that met with in persons
engaged in trades attended by the inhalation of irritating particles. Sometimes it
is a sequel to other pulmonary disorders.

Prognosis. — ^The prognosis is serious, because nothing will remove the fibrous
tissue. As regards the duration of life, the prognosis is good if the patient is not
losing weight and the disease is not too extonsive. The complicaiions are bronchiectasb,
a very frequent sequel, dilated right heart, and emphysema occurring in other parts
of the lung. When ulceration of the bronchi has taken place, lardace3us disease
and septicemia may ensue.

TreatmenL — Counter-irritation and respiratory exercises are given on the lines
advised in Chronic Phthisis (§ 94). Formula 61 is usefuL

§ 98. Thickened Plenra is a condition which sometimes succeeds dry pleurisy,
especially recurrent dry pleurisy. It is important to be able to recognise it, lest
it should be mistaken for some more serious condition, though it is somewhat difficult
to diagnose. It is more often localised to one part, and that most commonly at the
apex associated with chronic phthisis. The symptoms are : (i.) A localised enfeeble-
ment of the respiratory murmur; (ii.) dulness on percussion; and (iii.) diminution
in the vocal resonance and fremitus.

The diagnosis is arrived at (L) by the history of the case — e.g., there has been an
attack of pleurisy or pneumonia in the past — and (ii.) by the absence of signs of active
disease when the patient is kept for some time under observation. The condition is
often discovered only by chance, when the patient seeks advice for other ailments.
Treatment is of no avail ; and, if only moderate in degree, the disease is not of much
consequence. Counter-irritation may be applied.

§ 99. Malignant Disease of the Lung. — Cancer of the lung is rarely a primary
condition, but is most frequently secondary to cancer of the breast or abdominal
organs. The most common form of malignant disease, sarcoma of the mediastinum,
is described in § 54. A primary malignant growth tends to involve one lung ; secondary
growths tend to bo disseminated in both lungs. The evidences of the former are
usually more distinct than those of the latter.

Symptoms. — ^The lung trouble may be preceded by signs of malignant disease
elsewhere. The first evidence of involvement of the lung is breathlessness,
followed by cough and by expectoration, which may from time to time be tinged
with blood (" prune- juice sputum.") Pain is often present, and indicates generally
that the pleura is invaded, in which case there is usually a certain amount of pleuritic
(blood-stained) effusion.

The Physical Signs are often very indefinite. Clinically, there are two forms —
(a) The nodvlar form is usually attended by serous effusion (see Hydrothorax, § 95).
Effusion into the pleura coming on slowly, or returning persistently, in an elderly
person not the subject of phthisis is of itself suspicious, and the diagnosis is con-
firmed when, on aspiration, the fluid is found to be blood-stained. Sometimes in the
midst of what appears to be a hydrothorax we detect the signs of consolidation. This
probably indicates that the neoplasm has come to the surface in one locality.

(6) With the infiltrated form we find signs of consolidation, accompanied later on
by the moist sounds due to the breaking down of the growth. Here again nearly
every variety of physical sign may be met with in different parts of the lung, and if
the main bronchus be obstructed, there is entire absence of the breath sounds.

Diagnosis. — ^The condition has to be diagnosed from different forms of pneumonia,
from pleurisy with effusion, and from hydrothorax. The type of cell found in the
effusion after paracentesis is diagnostic in many cases. The age of the patient, the
course of the affection, the absence (usually) of muoh pyrexia, the presence of enlarged
glands and cachexia, should enable us to come to a conclusion.

172 THE LUNGS AND PLEVRM [ §§ 99a, 100

Prognosis, — Tho quostion is one of duration, and this can only be gauged by daily
obsoryation of tho caeo, and by noting the rate at which the growth appears to be
spreading. Death usually occurs in about six months.

Tho Treatment resolves itself into the relief of pain and the amelioration of other
symptoms which may be present.

§ 99a. Hydatid Csrsi is a more frequent disease of the pleura or of the lung in
Australia than in this country. No symptoms may be experienced by tho patients
for a long time. If superficially situated, it causes bulging of the chest waU. The
physical signs resemble those of pleural effusion, but tho dulness has a more rounded
outline. When a cyst occurs at the apex of a lung, it is usually mistaken for tubercle.

The diagnosis may be impossible from examination of tho chest, until the X rays
are employed. Eosinophilia is always present, and aids tho diagnosis. The char-
acteristic booklets may be expectorated, and hydatids may be present in other
organs. The serum of the patient gives a specific precipitin reaction.

Prognosis. — The cyst may rupture into tho pleura or into tho lung, and cause
haemoptysis or abscess. Serious constitutional symptoms may arise from the onset
of suppuration. Or it may open into a bronchus, thus leading to spontaneous recovery.

The treatment is mainly surgical.

§ 100. Atelectaiis, or Collapt e of the Long, is a condition in which the lung tissue
is in an unexpanded state. The term ** atelectasis '' is usually applied to lung tissue
which has never properly expanded, a congenital condition, duo to imperfect develop-
ment. The term " collapse of tho lung " is applied to lung tissue which has previously
expanded, but in which the air vesicles have subsequently collapsed.

Atelectafis is a congenital condition, of which symptoms occur in tho new-bom
child, and consist of cyanosis, with shallow, rapid respiration. The lower part of the
chest is drawn in by each respiration. On auscultation, the respiratory murmur
is found to be very faint.

The Symptoms of coUapse of the lung follow and complicate those of tho disease
which has led to tho condition ; for instance, the patient may not recover so rapidly
as he ought, or tho breathing is more embarrassed than can be accounted for by
the concurrent disease in the chest. Tho physical signs vary considerably with tho
degree of collapse. Thus :

(a) In comflete collapse of a part of the lung, as, for instance, in collapse due to
compression or complete obstruction of a bronchus high up, there is impairment of
tho percussion note, with a diminution or absence of tho breath sounds, and of the
vocal resonance and fremitus.

(6) Where the collapeo is only partial in degree — e.g., where the bronchi remain
patent, as occurs sometimes when the lung is compressed by pleuritic or pericardial
effusion — there are signs resembling those of consolidation (§ 77), except that the
percussion dulness is not so marked, and the breath sounds, though bronchial in
character, are somewhat feeble.

(c) ^Vhere the collapse is slight and limited, the chief sign is an enfeebled respiratory
murmur. In addition, during deep inspiration are heard fine rustling crepitations,
due to the expansion of the collapsed vesicles.

The Diagnosis is made usually by the existence of a causal condition. W^hen
this is detected, attention may then be directed to the physical signs of the lungs.
It will be observed that the signs of partial collapse resemble the signs of consolida-
tion, and those due to slight collapse resemble early pneumonia.

Etiology. — The causes are of throe kinds : (a) Causes which produce obstruction,
such as (i.) a tumour at the root of the lung (e.^., aneurysm) ; (ii.) obstruction in
the throat {e.g., adenoids) ; (iii.) stricture of a bronchus {e.g., gumma); (iv.) secretion
obstructing the bronchi, though this is only sufficient to cause obstruction n children
Buffering, for example, from whooping-cough, or broncho-pneumonia ; (v.) foreign
todies oh struct ng the larynx or bronchus.

(6) Compression of tho lung may be produced by pleural or pericardial effusion,
an enlarged heart, or tumours of the mediastinum, or of the abdomen. The condition
is often the result of spinal curvature. It may occur after abdominal operations and

§1 101, 102 ] SYPHILIS OF THE LUNG-^EMPHYSEMA 173

ansesthosia, and givo rise to difficulty in diagnosis, unloss the possibility of its occurrence
is borne in mind.

In adults collapse is most often met with as the result of pleural effusion or tumours
in the chest ; in children, of bronchitis or broncho-pneumonia.

Prognosis. — ^The course of the disease depends very much upon the caus3. Recovery
as a rule soon takes place after compression by effusions, obstruction or stricture of
the bronchi, and throat affections.

The TnalmerU is unsatisfactory. It should be directed to the removal of the
causo, and especially to the promotion of recovery of any concurrent pulmonary
disorder. That form which yields best to treatment is mot with in children with
bronchitis and broncho-pneumonia. In adults it might be well to try the efficacy
of respiratory exercises.^

§ 101. Syphilis of the Long. — In infants this disease may take one of two forms :
(a) The pneumonic condition of lung, which is found in infants, usually stUl-bom, is
universally regarded as an interstitial pneumonia of syphilitic origin. (6) Qummata
are occasionally mot with in the lungs of infants who are the subjects of hereditary
syphilis ; still more rarely they are met with in adults. Dyspnoea is usually the only
symptom. The signs are those of consolidation, and collapse. In adults syphilis
of the lungs may take other forms — e.^., broncho-pneumonia, bronchiectasis, etc. —
and may lead to extensive infiltration and breaking down, or to fibrosis.

Group C. — Chronic Diseases attended by Hyper-rejonanoa on per-
cussion : I. In quite nine out of ten cases of hyper-resonance it exists on
both sides, and is due to Emphysema. There are five other conditions
which give rise to it — namely : II. Pneumothorax (§ 89) ; III. Skodaic
Resonance (§ 75) ; IV. A very large cavity in the lung (Phthisis, § 94) ;
V. A Tumour between the chest wall, and a large bronchus (§ 99) ; VI.
Dissemination of Solid Material through the lung in certain excep-
tional circumstances {e,g,, pneumonia, sarcoma, etc.). The diagnosis of
these various conditions is given in the form of a table (p. 174). All except
Ebiphysema are described elsewhere.

I. The jxUient has complained of breathlessness for some years. There is
hyper-resonanoe on both sides of the chest. The disease is Emphysebia.

§ 102. Emphsrsema is a chronic non-febrile disease of the lungs in which
the air vesicles become hyper-distended, the walls separating each vesicle
become atrophied, inelastic, and ruptured, and as a result the aerating
surface is greatly diminished, and the lungs deficient in their elastic
recoil.

Symptoms, — (1) The onset of the disease is imperceptible, and generally
supervenes gradually after repeated attacks of bronchitis, the patient
becoming more and more breathless after each attack. (2) This breath-
lessness is practically the only symptom, and it differs from all other
kinds of breathlessness in this, that the chest remains permanently in the
inspiratory position — in other words, owing to the inelastic state of the
lungs and the shape of the chest, the patient finds it more difficult to
expire than to inspire. A certain degree of cyanosis is generally present.
(3) Symptoms of bronchitis are nearly always present,

^ " Respiratory Exercises in Treatment of Disease, notably of the Heart, Lungs,
Nervous and Digestive Systems," by Dr. Harry Campbell. London, 1899.

174

THE LUN08 AND PLEURJS

[§102

Table IX.— Causes of Hyper-resonance.

Cause.

I. Emphysema.

II. Pnenmotliorax.
mostly Hydro-
pneumothorax.
An acute condi-
tion.

in. 8ko<laic Reso-
nance— i-e., the
high-pitched
note above a
large pleuritie
efftuion^ when
the lung is other-
wise healthy.

IV. A very large
cavity, or ex-
tensive bronchi-
ectasis (rare).

V. A Tomoor (or
pneumonic^con-
solidation) be-
tween the chest
wall and a lar^e
bronchus (rare;.

VI. Infiltration of
solid and even
fluid material
through the lung.
e.g.f early stage
of pneumonia,
miliary tubercle,
etc. (rare). i

Hyper-resonance.

Bilateral and uni-
versal.

Hyper- resonance
always unilateral,
though it may extend
beyond middle line.

Unilateral: level
may shift with posi-
tion of patient.

Auscultation.

R.M. distinct and
expn. much pro-
longed ; signs of bron-
diitis, if present.

Absence of R.M.
and V.F. over af-
fected area ; some-
times amphoric
breathing. Bell
sound.

Loud R.M. ; V.F.
felt over affected
area.

Other Diagnostic
Features.

Barrel-shaped
I chest, cardiac dulness
obscured, and organs
I displaced.

Organs displaced ;
history of emphysema
or tuberculous cavity.

History of pleurisy;
signs of fluid lower
part of chest.

Unilateral, and of
limited extent (may
be cracked-pot sound).

Unilateral, and of
limited extent; dul-
ness elsewhere.

Hyper -'resonance
not marked (may be
bUateral). ~

AmphoriC| Expectoration of
breathing, whispering i pus and long history
pectoriloquy. * of phthisis or bron-

: cliitis.

Tubular breathing
md bronchophony.

Symptoms of intra-
thoracic tumour.

Signs of consoUda-
, tion in some parts.

Hy];>er-re8onance
generally transient.

The Physical Signs, expressed briefli/y are a barrel-shaped chest, hyper-
resonance, and prolonged expiration. The shape of the chest is special
to emphysema (see Fig. 34). The chest assumes permanently the shape
of a healthy chest in a position of deep inspiration. The antero-posterior
diameter is considerably increased (see § 74). The h3?3)er-resonance is
always bilateral, and it obscures the dulness of the neighbourmg organs
— namely, the heart, the liver, and the spleen. These organs are also
displaced downwards. The apex-beat may not be palpable, but epigastric
pulsation is usually felt. On auscultation, the respiratory murmur is
modified ; the inspiratory sound, which is full, is followed by a pause, and
then by a prolonged expiratory sound. There are no adventitious sounds
proper to emphysema, but, as just mentioned, bronchitis {q-v.) nearly
always accompanies it. The heart sounds, especially at the base, may
not be heard, or only with difficulty. Well-established emphysema inter-
feres considerably with the pulmonary circulation, on account of the
ruptured alveoli, and consequently the right side of the heart in course of
time becomes dilated.

§ 102 ] EMPHYSEMA 175

Variety. — In old people there is sometimes hyper-resonance with
weak breath sounds, but no enlarged barrel chest; this is called
Atnyphic Emphysema, and is due to the giving way of degenerate air
vesicles.

The Diagnosis is extremely easy, because the bilateral hyper-resonance,
the prolonged expiration, and the barrel-shaped chest are quite charac-
teristic (vide Table of Diagnosis).

Etiology, — (i.) Emphysema occurs usually in elderly subjects. Both
sexes are affected, but it is much commoner in males owing to the preva-
lence of bronchitis and asthma in them, (ii.) Heredity is said to play
no part in the disease, but imdoubtedly a hereditary tendency can fre-
quently be traced, (iii.) Certain occupations render people prone to
emphysema — i.e., those which throw strain upon the lungs, as in the case of
glass-blowers, wind-instrument blowers, etc. (iv.) The disease is frequently
associated with senile degeneration, chronic Bright's disease, and cardio-
vascular changes, (v.) Bronchitis is the most frequent of the exciting
causes, owing to the prolonged coughing and straining to get up phlegm,
and owing also to the blocking of certain tubes with thickened secretion,
which prevents the access of air to some alveoli, and unduly distends
others, (vi.) Asthma is also a potent exciting cause, owing to the con-
stant strain on the elastic tissue of the lungs.

Prognosis. — Patients may live with emphysema to a good old age, and
provided it is only moderate in degree it does not necessarily shorten life,
though it predisposes to, and adds to, the seriousness of other pulmonary
disorders. The gravity of any particular case is best measured by the
extent of cardiac involvement (q.v.).

Treatment. — The indications are : (i.) To relieve the accompanying
bronchitis (see § 93) ; (ii.) to improve the cardiac condition ; and (iii.) to
restore as far as may be the elasticity of the hmgs. The diet is of con-
siderable importance in advanced emphysema, for any distension of the
stomach greatly adds to the respiratory distress. It is a good rule never
to let patients take a solid meal later than two o'clock in the day ; other-
wise their nights become considerably disturbed by the breathlessness.
Cardiac tonics, especially strychnine, and, in my experience, tinctura cacti
grandiflori, are useful. Quinine and cod-liver oil often do good, although
I cannot explain how the latter acts.

To lostoie the elasticity of the thorax is important, but difficult to accomplish ;
of late years a special form of respiratory exercise has been put forward as fulfilling
this condition, and to relieve the difficulty of expiration. With this end in view,
Gorrhardt^ has recommended the employment of mechanical expiration by com-
pression of the thorax methodically, every day for five or ten minutes, by another
person, who places his two hands flat upon either side of the patient's chest. A
similar result has been attained by Bossbach*s Althomstiihl (breathing-chair). In
view of the fact that in many oases the maintenance of the inspiratory position is
due to calcification of the costal cartilages, division of the latter has been attempted
successfully by some sui^geons.

^ Strumpel's " Pathologic und Therapie."

IV r. THE LUNOS AND PLEURA [ §§ 108, 104

Group D. — There are three chronic pulmonary conditions in which the
percussion note varies considerably in different cases, but the ffensive
character of the sputum reveals their presence — ^viz. : I. Bronchieotasis ;
II. Gangrene ; and III. Abscess of the Lung. In Abscess the sputum
is not so invariably offensive. IV. Actinomycosis and other diseases due
to fungi affecting the lung can usually be diagnosed only by examination
of the sputum.

§ 108. Bronchiectasis. — Bronchiectasis is a cylindrical or saccular dilatation of the
bronchial tubes. The condition is met with most frequently as a complication of
chronic bronchitis or chronic pneumonia.

Symptoms. — ^The patient complains chiefly of persistent cough. At intervals of
several days violent increase of coughing occurs ; it is started, perhaps, by some
change of posture, and is followed by the expectoration of a large quantity of extremely
foetid sputum. In the intervals the sputum is scanty, but the breath is offensive.
The foetid sputum contains pellets or " Traube plugs," and sets characteristically in
throe layers (see § 78).

The Physical Signs, if present, are mostly those of a cavity, attended by general
signs of chronic bronchitis in both lungs ; occasionally only one is affected. The
patient is often cyanosed, and has clubbed fingers.

Diagnosis. — ^The extremely foetid odour of the sputum — occurring as it docs at
intervals of perhaps several days or weeks, during which the sputum is not foetid — distin-
guishes bronchiectasis from all other diseases. In gangrene of the limg the sputum
may be foetid, although in a loss degree, but it lacks the intermittent character.
The position of the bronchiectasis is generally marked by dulness in the lower lobe
of one lung, which may bo made to disappear by making the patient lie face down-
wards for some time, with his head low, till he coughs up a large amount of sputum.
The causes of the two affections also aid the diagnosis. Abscess of the lung is attended
by a very profuse purulent expectoration, but it is not so foetid.

Etiology. — (i.) In patients past middle life by far the most usual cause is prolonged
chronic bronchitis, and in children whooping-cough. The dilated bronchial tube
results from the continual strain of coughing on the weakened walls, (ii.) Various
forms of chronic pneumonia and chronic phthisis are believed to be attended by
bronchiectasis, but in such cases it is probably a cavity in the lung tissue, and not
true bronchiectasis, that we meet with, (iii.) A foreign body plugging a bronchus
is an occe^onal cause, (iv.) In very raro cases it is a congenital defect.

Prognosis. — The condition is a very serious one, and for the most part incurable.
The patient may live from one to ten years. The prognosis is much worse in bilateral
cases, or in cases associated with extensive disease of the lungs or pleura.

The Complications which may occur are fatal haemorrhage, gangrene of the lung,
lobular pneumonia, and pysemia.

Treatment. — ^The indications are to relieve the disgusting foetor and to cure the
primary disease. The first is accomplished by liberal antiseptic inhalations of tur-
pentine, coal-tar, or creosote.^ The most valuable form of treatment is the oroosote
vapour bath. Patients are placed in an air-tight room, in which creosote is volatilised,
the time of exposure being gradually increased from five to twenty minutes. Terebenc
and creosote may be given in capsules (4 minims) three times a day. Some inject
menthol or guaiacol into the trachea in the proportion of 5 and 2 grains in 1 drachm
of olive oil twice a day. When the cavity is low down and near the surface, suigical
measures for its drainage have been adopted.

§ 104. Gangrene of the Lung. — Owing to the extreme vascularity of the pulmonary
tissues, gangrene of the lung is a rare condition, but it occasionally occurs over a
limited area. It is usually a secondary condition, but it sometimes occurs in a lung
previously healthy.

Symptoms. — (1) The onset may bo acute, and marked by prostration and an irregular,
intermittent pyrexia of a pya>mic typo, with a very rapid pulse. (2) If, as is usual,

1 Brit. Med. Journ., June 22, 1895.

§! 104, 105 ] ABSCESS OF THE LUNG 177

the gangrenous part opens into the bronchi, a profuse foatid expectoration soon
follows. The sputum contains fragments of lung tissue, and generally blood also.
The breath is extremely foetid. (3) Pain in the side is usual, though it depends upon
the involvement of the pleura. There is persistent cough, which aggravates the pain.
(4) The Physical Signs are those of consolidation, sometimes those of a cavity.

Diagnosis, — ^The only condition which is liable to be mistaken for it, by reason
of its foetid expectoration, is bronchiectasis, which is distinguished by having
(i.) " Traube plugs '' in the sputum, and (ii.) a gradual onset and longer course.

Etiology. — It is predisposed to by intemperance, old age, diabetes, and marasmus.
Exciting causes are : (i.) Particles of food entering the limg, as in the insane, or patients
with laryngeal paralysis, or persons in a drunken coma. In children a foreign body
swallowed may produce it, though rarely, (ii.) Septic matter passing from the throat
or mouth, (iii.) Severe asthenic t3rpes of pneumonia are occasionally so complicated,
(iv.) It may complicate bronchiectasis, (v.) Septic emboli, (vi.) Aneurysm pressing
on the root of the lung. (vU.) The extension of an abscess near the lung.

Prognosis. — ^The disease is almost invariably fatal, either immediately from collapse,
sometimes from fatal haemorrhage, or, later, from prostration. A few cases have
recovered where the patch was of small extent. In cases which have been recorded
as lasting for months or years it is veiy doubtful whether the lesion was true gan-
grene ; bronchiectasis is more probable. Occasionally the condition leads to pyo-
pneumothorax.

Treatment. — Keep up the strength of the patient by means of abundant nutritive
stimulants, iron and quinine. For the rest, the treatment is the same as in bronchi-
ectasis. Surgery has succeeded in some cases.

§ 106. Abscess of the Long is a serious and, happily, rare condition, but as it is
nearly always secondary to some grave or fatal disorder, it does not add very materially
to the gravity of the situation.

It is usually manifested by the expectoration of a large quantity of purulent pus,
which may or may not be foetid, and is never so foetid as in bronchiectasis or gan-
grene. The constitutional disturbance to which it gives rise is usually masked by
that of the primary malady. Thf Physical Signs are those of localised consolidation,
but these also are generally masked by those of the primary lesion. When the abscess
bursts, the signs are those of a cavity.

It may occur in the course of (i.) advanced pulmonary tuberculosis ; (ii.) pneumonia ;
(ui.). pyaemia ; (iv.) cancer, suppurating hydatid, or other tumours of the lung, such
as a gumma breaking down — a somewhat rare condition ; (v.) it occasionally follows
the introduction of septic foreign bodies or wounds in the throat.

Prognosis. — ^The prognosis is very grave, but depends upon the cause. Occurring
in the course of pyaemia, it indicates the progress towards a fatal termination. It is
less grave in pneumonia occurring in otherwise healthy persons.

Treatment. — ^Medical treatment is not of much use. Surgical interference is not
good in malignant and pysemic conditions, but in other conditions, if fairly superficial,
the abscess may be drained.

§ 105a. Actinomycosis may affect the pleura or the lung, imitating the signs of
empyema, pneumonia (§ 876), phthisis, or bronchiectasis. In the absence of cutaneous
or other lesions it is rarely diagnosed except by an examination of the sputum, when
the little yellow pellets containing the ray fungus are visible. The blood serum gives
a specific agglutinin reaction. The disease is usually fatal.

Aspergillosis. The fungus aspeigillus fumigatus may cause signs resembling tuber-
culosis. The disease affects pigeon-feeders, who chew the seeds containing the fungus.
It may undergo spontaneous resolution.

Blastomyces may affect the lungs. Cutaneous and other lesions are usually present
in addition.

CHAPTER VII

THE UPPER RESPIRATORY PASSAGES AND THE THYROID

GLAND

The throat may be the seat of the same morbid processes as affect other
mucous structures, such as catarrh, ulceration, or new growths. It is,
moreover, in this position that several very important general or con-
stitutional maladies, such as diphtheria, scarlatina, and syphilis, have
important local manifestations. These facts have long been known, but
it has come to be recognised only quite recently that the throat, and
especially the tonsils — organs whose functions are still imperfectly known
— may constitute the portal of entry of certain microbic conditions. It
has also been suggested that the virus of influenza, rheumatism, malignant
endocarditis, and other septic conditions, thus gain admission into the
general systemic circulation.

This chapter will deal with the symptoms referable to the iihar3nix
(§ 106), the larynx (§ 119), the nasal cavities (§ 129), and the thyroid
gland (§ 135).

THE THROAT.

§ 106. Symptomatology. — " The throat " may be said to consist of the
fauces, tonsils, palate, pharynx, and larynx, and we are here concerned
with the investigation of these structures. The symptoms indicating
disease of these parts are principally two — namely. Sore Throat and
Hoarseness. The examination of the mouth and tongue is described
imder Disorders of Digestive Tract (Chapter VIII.).

(a) Sore Throat is indicative mainly of disease of the pharynx, tonsils,
and structures around. If the patient complains of " sore throat," turn
to § 108.

(b) Hoarseness and Other Alterations of the Voice are indicative
of some affection of the larynx (§ 119). If Nasal Intonation or Nasal
Discharge be present, turn to § 129.

There- are also several minor symptoms which arise in conjunction with
these, such as a dryness accompanied by tickling sensations, or an exces-
sive secretion, which leads to " hawking " and " coughing." Thus it
happens that we may be consulted for what the patient believes to be

178

SIWJ CLINICAL INVESTIGATION 179

polmonary disease, wKeit in reality the lungs are perfectly Iiealtliy.
Dyspacsa and dysphagia may also be produced by local conditions of
the throat and laryni. " Globus," or paroxysmal sensations as of a ball
in, or constriction of, the throat is a symptom of hysteria.

g 107. CUnical Investigation. — The anatomy and relations of the throat
are indicated in Fig. 48 ; the various parts may be investigated by
(a) direct, and (6) indirect {i.e., laryngoscopic) examination.

(o) For the Dieect Exauination of the fauces and neighbouring
structures all that ia necessary is a good light and a spatula or spoon to

Fig. 48. — NiBAI IND BnccjL CAViriES, ihoirlng tbe method ol LARTNaoscawo EXASmATiOn. —
The threo turWnato bonei are Been, the interior and of the Inferior turblaata boDa having been
lemoved to ibaw the inner opening o[ the lachrymal duct. The opening of the Emtaohlan
tube la Inst bsblnd the poatcrloc end of the Inlenoi turbinate bone. The exact pojltlon of
laryngofcoplo mirror In examination of larynit Is «hown — naniely, over the root of the uvula.

depress the tongue. If direct daylight is not available — as for instance,
when the patient is in bed — a laryngoscopic mirror can be used {vide
tn/ra), or a wax vesta, with or without a bright spoon behind it to act
as a reflector. The patient should be instructed not to strain, and to
" breathe tptiedy in and oui." The posterior wall may be seen by directmg
the patient to say " Ha — ah," in which procedure the soft palate is raised.
Note should be made of the colour of the mucous membrane, the presence
of exudation or ulceration, of granulations oi adenoid vegetations in the
pharynx, of any mucous patches such as occur in syphilis, or any bulging

180 THE UPPER RESPIRATORY PASSAGES [ $f 108, 109

of the pharyngeal walls. The size and length of the uvula should always
be observed, for a long uvula may be the sole cause of chronic cough and
numerous otherwise unexplained symptoms. When a patient complains
of cough coming on, or getting worse, at night or when he lies down,
elongated uvula should be suspected. It does not follow that such a
uvula may appear too long at the time of inspection. Temporary con-
gestion from various causes — e,g,y much talking — produces undue elonga-
tion and nocturnal cough. Painting with tannin may reduce it, but the
proper treatment is amputation, and it is wonderful what immediate relief
is obtained.

(6) The Indirect or Laryngoscopic Examination of the throat is
given in § 119.

§ 108. Classiflcation, Diagnosis, Prognosis, and Treatment. — Sore Throat

is a symptom common to nearly all diseases of the throat. Mentioned in
order of frequency, the diseases which give rise to sore throat are as follows
(laryngeal affections being eocdudedfor the f resent ; see § 119) :

Commoner Causes. Rarer Causes,

I. Catarrhal pharyngitis, including two VI. Retro-phaiyngeal abscess or tumour,

acute and three chronic varieties. VII. Phlegmonous sore throat and acute

II. Tonsillitis. oedema.

III. Scarlet fever. VIII. Cancer, and other new growths.

IV. Diphtheria. IX. Tuberculosis.

V. Syphilis. X. Other acute specific fevers.

§ 109. I. Acute Catarrhal Pharyngitis is an inflammation of the mucous
membrane of pharynx and soft palate, and to a certain extent of the
tonsils also. It may be so mild as to cause only slight discomfort in
swallowing, dryness of the throat, tickling and hawking, and in such
mild cases there is only a moderate congestion of the parts. But in
severer cases there are constitutional symptoms of some severity, and
locally there may be oedema and ulceration. The temperature in such
cases varies from 100° to 104° F. The disease rarely lasts more than a
few days, ending generally in resolution, although sometimes it passes into
a chronic condition.

Hospital Sore Throat is a severe variety of the preceding, attended by
considerable ulceration upon the fauces, tonsils, and even pharynx.
There is the greatest difficulty in swallowing, speaking, and sometimes
in breathing. The submaxillary and cervical glands are enlarged, and
there is often considerable pyrexia and constitutional disturbance, the
prostration being out of all proportion to the local inflammation.

(a) Chronic Catarrhal Pharyngitis presents the same symptoms as the
acute variety, in a milder degree, and extending over a longer period of
time. It is often known as Relaxed or Relapsing Sore Throat, on account
of the chronic congestion of the parts and the consequent predisposition
to the repeated occurrence of subacute attacks. It forms one variety of
clergyman's or school-teacher's sore throat.

§109] CHRONIC PHARYNGITIS 181

(6) Granular (Follicular) Pharyngitis is a chronic condition, the local
symptoms of which resemble the foregoing, with the addition of visible
granulations on the pharyngeal walls due to the enlargement of the
follicles 1 ; hence it is sometimes called follicular pharyngitis. This is a
common condition, and a person who is the subject of it, although ap-
parently in good health, is liable to suffer from repeated attacks of sore
throat whenever the weather is damp or his health a little below par.
There is excessive mucous secretion, which collects in the throat, especially
in the morning, and leads to chronic cough and hawking. When the
disease has lasted some time, the throat becomes dry from atrophy of the
follicles (Pharyngitis sicca).

(c) Granular (Adenoid) Pharyngitis is another form of chronic pharyn-
gitis, due to the presence of adenoid hyperplasia and vegetations in the
pharynx and naso-pharynx. They are sometimes confined to the naso-
pharynx, and by an ordinary inspection of the fauces little mischief,
excepting congestion, can be discovered. The lymphoid granulations may
involve a large part of the naso-pharynx, occurring as a large grooved
cushion or pedunculated growth, which, on examination, can be seen and
felt behind the soft palate. This condition is said always to start in
childhood. The child breathes with the mouth open, and thus acquires a
characteristic vacancy of expression. The intellect is often below the
average. The voice has a dull or nasal twang, and there are snoring and
disturbed sleep. The nares are narrowed, and the palate may be high
from the negative pressure in the nose, the diminished air tension in the
nose not counterbalancing the normal air tension on the buccal aspect of
the hard palate. Pigeon-breast may follow. The condition is a pregnant
cause of middle-ear catarrh and subsequent deafness. Adenoids in the
naso-pharynx are usually accompanied by chronic enlargements of the
tonsils. The disease often runs in families.

The Causes of pharyngeal catarrh vary somewhat in the different forms,
although the several causes are largely interchangeable. (1) There is no
doubt that in certain persons exposure to cold and damp is immediately
followed by an attack of pharjmgitis, but how far this acts as an exciting
cause, or whether, as in the possible case also of tonsillitis, the condition
is set up by a microbe which thrives xmder certain atmospheric conditions,
is not yet determined. (2) Unhygienic surroundings, such as bad drains,
the atmosphere of a hospital, and the like, may certainly give rise to a
very severe ulcerating pharyngitis (e.g., hospital sore throat) ; and here,
again, the cause may be a microbe. The same condition may arise in
private houses in which the drainage is out of order. (3) Bad health in
the individual affords undoubtedly a predisposition to the disease, and
especially to granular pharyngitis, so much so that the throat in some

^ The word " folliclo" is applied, not only to tho lacunar glands or crypts in tho
tonsil, but also to the localised collections of adenoid tissue found in the posterior wail
of tho pharynx. These latter, when enlarged, form the " granulations '* of the granula r
pharyn2L

182 THE VPPER RESPIRATORY PASSAGES [§109

persons constitutes a veritable barometer of the state of their health.
(4) The gouty and rheumatic diatheses offer a predisposition to pharyn-
gitis (compare No. 6 below). (5) Various local conditions, such as nasal
obstruction or insufficiency, leading to mouth-breathing ; and thus chronic
rhinitis and adenoid vegetations are potent causes of recurring "sore
throats." Excessive use or wrong methods of production of the voice
(clergyman's and school-teacher's sore throat), excessive smoking, the
constant use of alcohol, spiced or hot foods, or working in a dust-laden
atmosphere, often play an important part. The bristle of a tooth-brush
or a fish-bone impacted in the pharynx is a not infrequent though un-
suspected cause. (6) I have often met with chronic pharyngitis in people
who live too well. The excessive secretion and the perpetual hawking
which results have in several instances directed the attention of the
patient and of his medical adviser to the throat, larynx, or lungs ; but
the cure of these cases cannot be accomplished until dietetic and other
measures are directed to the relief of the portal congestion. (7) Pharyn-
gitis, especially in its chronic forms, is often associated with anaemia, and
iron is one of the most valuable remedies we have.

Prognosis, — Pharyngitis is one of the most frequent and troublesome of
the minor ailments which we are called upon to treat. The milder varieties
of the acute pharyngitis last only a few days, but the severer forms, such
as hospital sore throat, may last many weeks, and be followed by
considerable debility. All the chronic forms have a great tendency to
relapse.

Treatment. — The indications are to relieve the local inflammation, to
improve the general condition, and to prevent relapse. For the acute
forms, most of the remedies mentioned under Tonsillitis are available.
In all subacute and chronic forms, smoking, alcohol, and other causes of
local irritation must be avoided. Excessive secretion may be removed by
a gargle of bicarbonate of soda. For the " relaxed throat " a garglecon-
sisting of a wine-glassful of water, to which a pinch of salt has been added,
is useful ; so, also, are gargles of alum, potassium chlorate, and ammonium
chloride (Formulse 15 to 19). Probably carbolic acid, painted on as
glycerine (B.P.), or employed as a spray, gargle, or lozenge, is the best
application. A good spray is that of menthol (10 grains to the ounce of
paroleine). Later, astringent paints should be used — e.g., nitrate of silver
(20 grains to the ounce) or equal parts of tincture of iodine and the
glycerine of alum.

The most efficient treatment for the granular forms of pharyngitis,
where gargles are of little use, is painting with silver nitrate (40 or 80 grains
to the oimce), tannin (1 drachm to 1 ounce), or with liquor ferri per-
chloridi, or iodine in glycerine. Trichloracetic acid is recommended
highly. In cases of dry pharyngitis the ammonium chloride inhaler or
lozenges are very useful. The actual cautery may be used to the indi-
vidual granulations. All these measures, however, give only temporary
relief to the aderwid variety, when scraping away the vegetations is neces-

§ no ] TONSILLITIS 183

sary. For a permanent and radical cure these must be thoroughly
removed under general anaesthesia. Nasal obstruction, if present, must
also be relieved. The general health in certain forms, especially the
granular varieties, is often of more importance than the local condition,
and many a relapsing and granular pharyngitis can be cured by Blaud's
pills. Any rheumatic or gouty diathesis should receive attention, and
dyspepsia or constipation, especially if associated with portal congestion,
should be appropriately treated.

§ 110. IL Tonsillitis, or inflammation of the tonsil, is met with clinically
in acute and chronic forms. Peritonsillitis is sometimes described as a
variety ; it is an inflammation of the connective tissue in the vicinity of
the tonsil ; it accompanies catarrhal pharyngitis, and is sometimes due
to decayed teeth.

The three forms of Acute Tonsillitis are as follows :

(a) Acute Parenchymatous Tonsillitis (Quinsy, Acute Suppurative Ton-
sillitis). The symptoms are pain, swelling and redness of the tonsils,
coming on more or less suddenly with constitutional disturbance, the
temperature varying from 101° to 104° F. Cases without pyrexia are
occasionally seen. One tonsil is usually more affected than the other,
and there is pain, stiffness, and tenderness behind the angle of the jaw.
The disease usually subsides in the course of a week; if it lasts longer
than this, suppuration has almost certainly occurred on one or other side.
This is evidenced by the increased enlargement, by the swelling spreading
along the soft palate, backwards, and downwards into the pharynx. The
abscess usually bursts in the course of one or two weeks into the pharynx,
but it occasionally points in other directions.

(6) Acute Follicular Tonsillitis is of a more superflcial character. It is
attended by the same symptoms as the foregoing, with the exception that
abscess rarely occurs ; and the surfaces of the tonsils present numerous
yellow points of thick purulent secretion, and perhaps ulceration. There
are usually less fever and pain.

The Diagnosis of both these forms of tonsillitis from scarlet fever and
diphtheria is sometimes a matter of considerable difficulty, but one of
great importance. It is given in the form of a table (p. 186).

Etiology, — The function of the tonsils is still a matter of some imcer-
tainty, and therefore it is not surprising that the etiology of tonsillitis is
largely speculative. (1) Hereditary predisposition seems to play its part,
for tonsillitis often occurs in subjects having a gouty or rheumatic tendency.
(2) Unhygienic conditions, and especially bad drainage, have been credited
with causing the disease. (3) The tonsils become acutely inflamed in all
cases of scarlet fever, in diphtheria, and in so large a proportion of cases
of rheumatic fever that they are regarded as the portal of entrance of the
virus of that disease. (4) Cold and damp weather are certainly conditions
under which tonsillitis frequently arises. (5) Traumatism, such as drink-
ing out of a boiling kettle. Fish-bones and bristles of a tooth-brush
sometimes give rise to one-sided tonsillitis.

184 THE UPPER RESPIRATORY PASSAGES [fUO

(c) A rare fonn of acute tonsillitis is known as Vincent*! Angina. Care must be taken
not to mistake for diphtheria a form of sore throat first described by Vincent. It is
characterised by one or more patches of exudation, often presenting a necrotic appear-
ance, on the tonsib or adjacent anterior pillar, and sometimes encroaching on the
palate. The pellicle is not easily detachable, and leaves a shallow ulcerated surface,
the healing of which may be somewhat tedious. It is attended by some pyrexia and
a variable amount of constitutional disturbance. Whether or not ** Vincent's Angina "
should be regarded as a specific infective process is not clearly proven. Examination
of a swab from the affected surface will reveal the presence of a large fusiform bacillus,
which stains readily with the ordinary aniline dyes, but which will not grow on
ordinary culture media, and a delicate mobile spirillum. Both these organisms,
however, may be found occasionally in cases of ordinary ulcerative stomatitis, in
carious teeth, and in some cases of septic scarlet fever. There is reason to regard the
affection as infective, and in an *' exudation throat *' in which no diphtheria bacilli
can be detected the possibility of Vincent's Angina should be remembered.

Chronic Tonsillitis occurs in two forms. That form chiefly seen in
adults after repeated attacks of acute tonsillitis is due to a fibroid degenera-
tion, and is known as relapsing tonsillitis or chronic fibroid tonsillitis.
The other and commoner form is that seen in children, which consists of a
parenchymatous hyperplasia. The condition is almost always associated
with adenoids in the naso-pharynx, and consequently there are snoring
and mouth-breathing.

Course and Prognosis, — Acute tonsillitis is a frequent, and sometimes
very troublesome, but never fatal, disease. Sometimes the patient con-
tinues at work, but at others he is totally incapacitated. Chronic ton-
sillitis is important, because it renders the patient liable to repeated
attacks of acute tonsillitis and coryza. It is a common source of recurrent
pharyngitis, leading to otitis media and deafness. Enlarged tonsils met
with in children occasionally disappear during adolescence ; but in some
way, only imperfectly explained, the mental and physical development of
children who have chronic enlargement of the tonsils is sometimes im-
peded. It is, however, doubtful whether the development of the child is
hindered unless there be concurrent adenoids, which interfere with the
respiratory or oxidative processes of the body.

Treatment, — The indications are (a) to reduce the local congestion ;
(6) to reduce the pyrexia ; and (c) in chronic tonsillitis to prevent relapse.

(a) Powdered sodium bicarbonate applied directly to the tonsils has
been credited with aborting the disease. A cocaine spray (4 per cent.)
relieves the pain. Cold or hot compresses externally, steam inhalations
warm gargles of potassium chlorate, sodium bicarbonate, salol, and weak
alum or carbolic acid (1 in 100) or formalin (2 per cent.) relieve the con-
gestion (Formulae 15 to 19). In subacute cases the tonsil may be painted
with pot. iod., gr. xv. ; iodine, gr. xii. ; ol. menth. pip., \\u, ; glycerine, §i.

(6) To reduce the pyrexia a brisk saline purge should be given at the
outset. Tincture of aconite (1 minim doses) may be given every half -hour
during the first few hours ; then sodium salicylate, as in rheumatism, salol,
or liquor ferri perchloridi. If quinsy does not clear up in a week, one
may be almost sure an abscess has formed, and should be incised. This
is best done with a curved bistoury, round which plaster is twisted to

!§ 111-118 1 VARIETIES OF SORE THROAT 185

within half an inch of the point, which should be directed inivards and
backtoards to avoid the internal carotid. Make a small incision ; then
insert a dressing forceps and stretch the opening.

(c) In chronic tonsillitis the most useful remedies are iron, quinine, cod-
liver oil, and other tonics. Salicylic acid, guaiacum, and colchicum are
U3ed in the relapsing form. The chronic enlargement may be diminished
by painting the throat with glycerine of tannic acid (a most nauseous
preparation) or other astringents {vide supra). But in most of these cases
the question of tonsillotomy arises sooner or later. Parents sometimes
raise objections on the score that it may " impair the voice " or " injure
the health," but there is no reason to believe that this is ever the case.

§ 111. nL In Scarlet Fever the tonsil is generally the chief scjit of
inflammation in the throat. Both scarlet fever and acute tonsillitis
start more or less suddenly, with constitutional symptoms, and thus the
diagnosis is often one of considerable difficulty. There are four distin-
guishing features of scarlet fever — viz. : (i.) The diffuse scarlet colour
of the soft palate and pharynx, with complete immunity of the larynx ;
(ii.) sudden onset of the illness with high fever ; (iii.) on the second day
the rash ; and (iv.) about the third day the " strawberry " tongue (see
Table X., p. 186, and § 353).

§ 112. IV. The sore throat of Diphtheria may be recognised at once if
there be an ashy-grey patch of exudation upon the soft palate. When
this is absent it is chiefly with follicular tonsillitis that difficulties arise.
In diphtheria the large size and the colour of the patches (which are grey
with surrounding red areolae), the difficulty of removing them, and the
raw bleeding surfeice left, enable us to come to a conclusion. The onset
is more insidious, the pyrexia less marked, but the prostration is greater
in diphtheria. A muco-purulent or hsemorrhagic discharge from the nose
is very characteristic of diphtheria. The occurrence of albuminuria is
given by some as distinctive of diphtheria, but it is very frequently
observed in acute tonsillitis also. When other diagnostic features are
absent, the presence of one large patch on a tonsil, instead of several small
patches, is in favour of diphtheria.

§ 113. V. Syphilitic Sore Throat is very characteristic. This and the
other secondary manifestations of syphilis come on about three to six
weeks after the appearance of the chancre. (1) The tonsils may be in-
flamed, but the inflammation is more generalised, and the mucous mem-
brane presents greyish- white semi- translucent irregular patches (" snail -
tracks"), on the fauces, tonsils, palate, and other parts of the buccal
mucous membrane. Superficial ulceration may also be present, especially
on the tonsils, with red punched-out edges and yellow-grey secretion.
(2) Bilateral symmetry is a very characteristic feature of all these lesions.

Tertiary syphilitic ulcers may produce sore throat, their favourite
position being the soft and hard palate, the tongue, and the fauces. They
are usually preceded by gummatous swellings. (1) The ulcers are deep,
with ragged floor, sharply cut edges, and covered with thick yellow-grey

186

THE UPPER RESPIRATORY PASSAGES

[§114

secretion. (2) They are progressive, and in course of time will destroy the
hard palate or any other parts they invade. (3) They leave characteristic
stellate cicatrices, which are indisputable evidence of the disorder.

Table X.

Tonsillitis.

Scarlet Fever,

Diphtheria,

Swelling and redness
chiefly confined to one or
both tonsils. In the fol-
licular form, tonsils covered
with sticky mucus, with
numerous small, separate
yellow spots of secretion
on one or both, which are
easily removable. Noth-
ing on soft palate.

(a) Local Signs.

Diffuse bright redness of
throat and palate gener-
ally. The tonsils swollen,
and may bo covered with
mucus, and sometimes with
multiple yellow points.
Nothing on soft palato in
ordinary cases.

(i.) Onset moderately
sudden, with moderate
fever.

[(ii.) Temperature may
be very high, but local
symptoms are usually
more troublesome than
general symptoms.

(6) General Syaiptoms.

(i.) Onset very sudden,
with high fever.

(ii.) Temperature very
high. Local symptoms
a subordinate feature.

(iii.) Rash on second
day.

(iv.) Strawberry
tongue about third day.

Ashy-grey patch or
patches on tonsils, uvula,
atid soft palate (latter situ-
ation is pathognomonic) ;
patches larger than the fol-
licular secretion in ton-
sillitis. Patches consist of
membrane surrounded by
rod areolae ; difficult to
remove, leaving raw sur-
face. Klebs-Lbffler ba-
cillus found in membrane.
Sometimes a muoo-puru-
lent, acrid nasal discharge,
0>mparative absence of
pain.

(i.) Onset insidious.
Early and marked enlarge-
ment of cervical glands.

(ii.) Temperature not
80 high at first, and may
remain low during whole
course.

(iii.) Paralytic soquelsB
sometimes.

The less frequent causes of Sore Throat are — Retro-pharyngeal Abscess,
Phlegmonous Sore Throat, Neoplastic Ulcerations, ard Acute
Specific Fevers.

§ 114. VI. Retro-phanmgeal Abscess, or inflammation of the lymphoid
and areolar tissue between the pharynx and the spine, may come on in-
sidiously, or it may be comparatively sudden. It is known by (1) the
rigidity of the head, with difficulty of swallowing and alteration of the
voice ; (2) evidence of swelling in the posterior pharyngeal wall on inspec-
tion and palpation, by which it is diagnosed from other causes of dyspnoea
in children.

Etiology, — Those cases with an acute onset are generally either part of a
septic inflammation after fevers, or occur in rachitic children under four.

§§ 115-118 ] PHLEGMONOUS SORE THROAT 187

Retro-phaiyngeal swelling coming on slowly is generally due to pus bur-
rowing from some adjacent structure, especially from caries of the ver-
tebrae.

Prognosis and Treatment, — The acute condition is always grave, and
requires prompt surgical interference, generally free incision ; meanwhile,
steam inhalations and warm fomentations relieve the symptoms.

S 115. Vn. Phlbomonous Sorb Throat — i.e.. Acute Septic Inflammation of the
Pharynx and Laiynx — or Angina Ludovici (when the inflammation is chiefly
external, in the nock).^ — ^This very severe disease may start inside the throat, with
Sjrmptoms of sudden pain, accompanied by considerable swelling, leading to severe
dyspnosa, stridor, aphonia, and complete dysphagia in a few hours. There is much
o&dema around the fauces, followed by a brawny infiltration of the skin of the neck,
spreading from under the jaw to the tongue and larynx. Sometimes the infiltration
starts exiemaUy, and rapidly invades the internal structures. There is groat con-
stitutional disturbance, and a temperature of 102° to 105° F., but unless pus forms,
rigors and delirium are generally absent. Pus formation is further indicated by
widely and irregularly intermittent pyrexia. Mild cases begin with a stiffness and
pain in the tissues around the jaw, and if recovery -s to take place, the symptoms
go no farther. But in many oases, and especially in alcoholic and debilitated subjects,
the disease rapidly progresses, and death takes place in twelve to forty-eight hours
from heart failure, coma, or asphyxia from oedema of the larynx. Suppurative forms
are very fatal. Among the recognised complications are pneumonia, pericarditis,
pleurisy, and meningitis. There is a more chronic form in which induration is in
excess of pus formation ; this may continue indefinitely until the pus is found and
drained.

Etiology, — ^The condition, happily, is rare, and the causes consequently obscure.
(1) It sometimes arises in association with scarlet fever, erysipelas, and small-pox (in
former times being a common cause of death in this disease), or other acute specific
fevers. (2) Dental suppuration or an alveolar abscess often forms the souree from
which rapid infiltration starts. (3) It may arise in people apparently in good health,
and has then been attributed to the entrance of a specific microbe by the tonsils, or
through the socket of an extracted tooth.

TrecUmenL — ^The indications are to control the inflammation, and to keep up the
strength of the heart. Quinine (4 or 6 grains) should be given every four hours.
Iron and digitalis are recommended. Remove carious teeth or stumps. Free and
early incisions should bo made into the oedematous tissues, and the practitioner
should be at hand to perform tracheotomy if the dyspnoea be increasing. Stimulants
must be liberally administered.

AcuTB (Edema of the throat may be part of the above disease when the oedema
is secondary to septic infection ; or it may be part of a general dropsy or angio-neurotio
oedema. It is dangerous, as it may spread to the larynx and cause death by suffoca-
tion (§ 121a).

§ 116. VnL Carcinoma frequently, and Sarcoma occasionally, affect the pharynx,
either primarily or secondarily. Their diagnostic features are the same as those
mentioned under The Tongue (§ 148).

S 117. IX. Tuberculous Ulcers of the pharynx are rare as primary lesions.
(I) They resemble syphilitic ulcers, but there is pallor of the mucous membrane, and
a characteristic ** worm-eaten *' appearance of the pharyngeal wall. (2) Their course
is not nearly so rapidly progressive. (3) It may be possible to obtain the tubercle
bacillus from the scrapings ; and (4) there are usually other manifestations of tubercle,
especially in the lungs. For treatment, see Tuberculosis of the Larynx (§ 123).

§ 118. X. Acute Specitio Fevers other than those mentioned above, such as
typhoid, give rise to inflammation and ulceration of the throat. In variola, for

^ The disease has been variously described by the following names : Acute Inflam-
matory (Edema, Erysipelas of the Throat, Phlegmonous Cellulitis, Acute Infectious
Phlegmon (a term applied by Senator when the inflammation was confined to the wall
of the pharynx).

188 THE UPPER RESPIRATORY PASSAGES §119

example, the pustules often form upon the palate, fauces, and buccal mucous mem-
brane, leaving superficial circular ulcers. An examination of the throat is often
useful as an aid to the diagnosis between measles, scarlet fever, and small-pox. The
first named always affects the larynx, rarely the pharynx ; scarlet fever always affects
the pharynx, and veiy rarely the larynx ; whereas small-pox affects them hoth about
equally. Patches of Lichen planus may be found on the palate when the disciaso
exists on the skin, and the eruption of varicella may be found in that situation. Other
patches may be due to thrush or T^erpes,

The Larynx*

§ 119. Symptoms and Clinical Investigation. — It will be remembered
that the two cardinal symptoms of diseases of the throat (used in its
widest sense) were (a) Sore Throat, and (b) Alterations of the Voice.
Both of these may be present in disorders of the larynx, but it is the
latter especially which indicates derangements of the organ of voice.
Diseases of the larynx are also sometimes indicated by Cough, Hawking,
Dysphagia, Dyspnoea, and actual Pain in the organ. But in some cases
all of these may be absent ; there may, indeed, be pronounced disease
of the larynx (e.^., paralysis or papilloma) without any subjective symp-
toms.^

The Clinical Investigation of the larynx (laryngoscopy) is a pro-
cedure of considerable technical nicety, and requires some practice. The
necessary appliances are a good steady light, a reflecting mirror mounted
on a band or a spectacle frame for the operator's forehead, and a small
circular throat-mirror mounted on a handle at an angle of 135°. The
light should be placed on a level with, and a little behind, the patient's
left ear. The operator takes his seat directly opposite ; and it is advisable
that his seat should be a little higher than that of the patient. Having
directed the patient to open his mouth and " breathe quietly in and out,"
the first step is to adjust the reflecting mirror in order to thoroughly
illuminate the back of the pharynx. The focal length of the head-mirror
is generally 10 to 20 inches, and this should represent the distance of the
mirror from the patient's pharynx. Having wanned the throat-mirror
over the lamp to prevent the moisture of the breath from settling upon it,
the next step is to pull with the left hand the patient's tongue gently out
of the mouth with the aid of the comer of a towel or a piece of linen rag.
Take the comer of the towel in the right hand, lay it on the patient's
tongue, then grasp the tongue and towel firmly between the left thumb
and finger. Take care not to hurt the under surface of the tongue against
the teeth of the lower jaw. Then test the warmth of the throat-mirror
against your cheek or the back of your hand, and, having pushed the
patient's head a little backwards by pressing your right thumb against
the upper teeth, introduce the mirror with the right hand, taking care to

^ Not long ago I met with the case of a well-known operatic singer who had a small
papilloma just beneath one vocal cord. Her voice was in perfect order, and she could
reach the highest notes with ease. The only defect was a hardly perceptible weakness
in the middle register.

5 IBO ] LARYIfOOaCOPY 189

avoid touching the top of the tongue in so doing. Push the mirror oblique!?
upwards against the soft palate just over its junction with the uvula
(Fig. 48, § 107). A good view of the vocal cords should be obtained
by slightly lowering or raising the handle. In children and persona with
very sensitive throats it is sometimes advisable to aniesthetise the pharynx
before laryngoscopy, either by a spray of, or painting with, a 4 or 5 per
cent, solution of cocaine, or by the admiuistration of a few doses of bromide
during the preceding twenty-four hours.

In normal conditions the epighttii, which is in reality anterior, appears
at the wpfer fart of the mirror. The vocal cords, which are of a peirly
white colour, are close together at their upper or epiglottic ends ; and at
their lower (really posterior) ends are widely divergent during quiet
respiration. At their lower ends they appear to terminate in two promi-
nent knobs seen at the lower edge of the mirror, which mark the position
of the arytenoid cartilagei

(Figs. 49 and 49a). The ._._ ,

ary-cpiglottic fdd» stretch on
each side from the aryte-
noids to the aides of the
epiglottis. In these folds,
iust external to the aryte-

' ., L -J u Fig. *B.— QiiiBtIn«p__ __. — . ..._

noid on each side, may be tion. Uon.

seen a small prominence,

the cartilage of Wrisberg. To the outer side of the cords lie the ven-
tricular bands or false cords of mucoua membrane. With a little
practice, and under favourable circumstances, the bifurcation of the
trachea may be seen.

Direct Larynooscopy is now practised. By means of Kiliian and
Briining's bronchoscope or the modifications of it, the interior of the
bronchi may be directly examined. When a foreign body has entered the
air-passages, the patient should immediately be X-rayed, then examined
by one who is expert in the use of this instrument.

In LiBYNuoscopif there am four MAiTEas to bo invoatigatod :
(a) Tho prosonco of congestion or ■pailor of tho vocal cords and the parts around.
CongeatioQ of the vocal cords is an evidoiico of Larvnoitis, Bometimos of ulcontion

(6) Tho preaanco of any lUceralion. Ulcoratioo occurring ii
ago is very often duo oithor to Svpnius or Tdbercle; in a
life it [3 not infroquontly ualiokant.

(d) Whothor thoro is any paraltjais or spasm of tho vocal cords, which is ovidonood
by the Biie, shape, and mobilily of tho aperture.

Wu Hhall doal with tho disoidora of tho laryni in this ordor.

§ 180. Clasfdflcation. — As just mentioned, there may be no subjective
symptoms even with pronounced disease of the larynx, and therefore it
will be well to adopt as a basis of cJasaification the physical signs discovered
by laryngoscopy. However, when symptoms are present there is always

190 THE UPPER RESPIRATORY PASSAGES [§121

some ALTERATION OP THE VOICE (cxcept, perhaps, bilateral abductor
paralysis, in which there may be dyspnoea and stridor without alteration
of the voice). The principal diseases giving rise to such alterations (i.e.,
the causes of alterations of the voice) may be grouped as follows :

I. Laryngitis —

(a) AciUe Laryngitis, including also —

CEdcma Glottidis, and

Foroign Bodios in tho Larynx or Trachea.

(b) Chronic Laryngitis, including also —

Perichondritis, and
Congenital Laryngeal Stridor.

II. Ulcerations of the Larjmx —

(a) Tuberculous Ulceration,
(6) Syphilitic Ulceration,
(c) Malignant Ulceration.

III. Nodules and New Growth —

(a) Benign,
(6) Malignant.

IV. Paralysis of the Vocal Cords —

Bilateral Abductor Paralysis.

Unilateral Abductor Paralysis,

Total (Ab- and Adductor) Bilateral Paralysis,

Total (Ab- and Adductor) Unilateral Paralysis.

V. Spasm of the Vocal Cords —

Laryngismus Stridulus (§ 128).

VI. Diseases of the Pharynx (§ 108) ; VII. Diseases of the Nose (§ 129) ;
VIII. Some severe Pulmonary affections; and IX. Certain
Neuroses also cause alterations in the voice.

1. The 'patient complains of huskiness or loss of voice, a comparatively
dry cough, soreness on simUoicing, and there are local signs of congestion
of the vocal cords. The disease is Laryngitis, of which two varieties ard
met with. Acute and Chronic.

§ 121. Acute Lanmgitis comes on somewhat rapidly, and usually runs
it i course in a week. As a rule it is not a serious affection, but in children
it may be alarming. In children a slight laryngitis coming on suddenly
is a frequent cause of what mothers describe as " croup." Owing to the
dryness of the cords, the child wakes up suddenly at night with loud
inspiratory stridor followed by an attack of coughing. This symptom is
technically known as laryngitis stridulosa, and is not to be confused with
laryngismus stridulus (see § 128). Simple laryngitis is differentiated
from membranous croup (laryngeal diphtheria) by the perfect general
health of the child in the former.

Etiology. — The chief cause of acute laryngitis is exposure to cold —
especially when combined with overuse and wrong production of the voice
(e.g., actors, music-hall artistes, etc.). It is frequently a part of the
" common cold." Diphtheria or measles may start in the larynx. Persons

§§121-128] LARYNOITIS-^aSDEMA OLOTTIDIS 191

who suffer from chronic laryngitis {q-v.) or nasal obstruction are predisposed
to attacks. A foreign body in the larynx or trachea is a cause of irritation
which may produce sjmaptoms resembling laryngitis.

Prognosis. — The affection is troublesome and apt to recur. When
occurring during the course of the specific fevers, the prognosis is less
favourable, because (Edema Glottidis may supervene.

Treatment, — All use of the voice must be forbidden. The patient must be
kept in a warm, moist atmosphere, and should use warm inhalations (such as
tr. benzoin co. 3i. to the pint of boiling water, and see also Formula 110).
Warm compresses or fomentations should be applied externally, and
warm mucilaginous and alkaline drinks should be freely taken. The
most efficacious medicine is one containing small doses of vinum anti-
monialis and potassium iodide. According to some, a strong solution of
silver nitrate (20 grains to 3i.) applied locally at the outset may cut short
the disease. For laryngitis stridulosa, apply hot sponges to the throat,
and give vin. ipecac, in teaspoonful doses, with warm water, every ten
minutes or so until emesis ensues. Adrenalin (iTLii.) may relieve rapidly.

§ 121a. (Edema Olottidif, or oedematous lar3rngitis, consists of an oedematous
swelling affecting the epiglottis and submucous tissue of the laiynx, but the vocal
cords are not involved. The onset is usually sudden, and attended by considerable
dyspnoea, dysphagia, and inspiratoiy stridor. The diagnosis is usually simple, on
account of the swelling which can be seen and felt on palpation at the back of the
tongue. If this be absent, some difficulty may be experienced, but the sudden onset
of laryngeal dyspnoea should bring the disease to our minds. It may arise either as
a primary or as a secondary affection. As a primary disease it may come on as part
of an acute septic inflammation of the throat, or it may be part of an oedematous
angio-neurosis of urticarial origin (see Acute CEdema of the Tongue). It may occur
as a secondary condition in association with (1) one of the various causes of acute or
chronic laiyngitis ; (2) a general anasarca ; (3) injury of the glottis by boiling or caustic
liquids, etc. Its rapid onset is the chief source of danger, but if the patient does not
shortly succumb to asphyxia, recovery generally takes place in a few days.

The Treatment consists in the administration of emetics, and ice internally and
externally. In severe cases, if a 20 per cent, cocaine spray fail, scarification of the
epiglottis must be resorted to ; and if this be imsuocessful, tracheotomy must be
performed without delay.

§ 1216. The Swallowing of a Foreign Body, and its passage into the larynx or trachea,
has always to be borne in mind in children suffering apparently from acute laryngitis.
for the history is often wanting. Paroxysms of dyspnoea or of coughing in a child
without obvious cause should make us suspect it. Unless it has passed into the
bronchus (usually the right), a foreign body may be seen by laryngoscopic examina-
tion. On the other hand, when a foreign body passes into the bronchus, it may cause
so little cough or disturbance at the time that the patient may imagine he has swal-
lowed it, or he may be unmindful of the incident. Some obscure cases of unilateral
bronchiectasis are probably due to such causes. When the presence of a foreign body
is suspected, a skiagram should be taken, and with the aid of direct bronchoscopy the
object may be removed even from the bronchus.

§ 122. Chronic Lanmgitis is a troublesome affection on account of the
perpetual hoarseness and liability to acute laryngitis. Its causes are
(1) repeated acute attacks; (2) excessive speaking, singing, teaching, and
overuse of the voice (actors, clergymen, school-teachers, etc.) ; it also
afEects masons, fustian-cutters, and others exposed to dusty atmospheres ;
(3) nasal obstruction and mouth-breathing ; (4) tubercle, syphilis, and

192 THE UPPER RESPIRATORY PASSAGES [§1280-128

new growths, the evidences of which should always be sought in cases of
intractable laryngitis. These usually go on to ulceration, under which
they will be described. (5) Spread of inflammation from adjacent parts.
Many cases of chronic laryngitis depend upon a granular condition of the
pharynx. (6) Rheumatic and gouty diatheses predispose.

Treatment. — The indications are to avoid the cause and to relieve the
local congestion. The removal of the cause is most important, and often
most difficult to accomplish, for a large number of the patients are singers,
teachers, and others whose living depends upon the daily excessive use of
the voice. The avoidance of tobacco and alcohol will aid, and residence
in a dry climate will often accomplish a speedy cure. Much may be done
to prevent or relieve the condition by proper voice-production and respira-
tion. This affection is extremely common among our board-school
teachers, owing chiefly to faulty voice-production, and they ought to be
specially trained to obviate this defect. Locally, painting with strong
astringent remedies, such as zinc chloride (30 grains to the ounce) or silver
nitrate (20 to 60 grains to the ounce), are useful. These strong applica-
tions should not be made more than twice a week ; weaker solutions can
be applied more frequently. The patient himself may use sprays of alum
(5 grains) or zinc sulphate (2 grains to the ounce) for five minutes twice
daily, or inhalations of turpentine, creosote, iodine, menthol, etc., for
fifteen minutes three times a day.

§ 122a. PerichondritiB is an inflammation of the perichondrium of the laryngeal
cartilages. Opinions differ as to its frequency. If considerable, it may lead to
necrosis of the cartilages and abscess of the larynx. The differential features, besides
loss of voice or hoarseness, are dull aching pain and acute tenderness. This may be
accompanied by swelling in the neck. As regards its Etiology, apart from traumatism,
it is rarely a primary malady. It more often occurs secondary to syphilitic oi
tuberculous laryngitis. Syphilis is its commonest cause. It also follows enteric
fever.

Prognosis and Treatment. — It is a serious affection, for even in the mild forms the
voice is rarely restored. Groat stenosis of the larynx may result. If there be much
swelling, the dyspnoea is very marked, and the patient may die from pneumonia or
gangrene of the lungs, or, in the suppurating forms, from pysomia. Abscess and
fistula may follow.

§ 1226. Congenital Laryngeal Stridor is a term applied to more or less continuous
inspiratory dyspnoea, accompanied by a croaking sound, occurring in infants. It
may be constant up to the age of two, or occur only at intorvab during that
period of life. It is believed to be caused by a folding of the epiglottis, possibly duo
to some malformation. It is usually attended by a certain amount of lar3mgitis and
hoarseness, and passes off without need for operative interference.

II. Ulcerations of the larynx are met with chiefly in tubercle and syphilis, and in
persons past middle life malignant disease may be a cause. The simple erosions present
in catarrhal laryngitis hardly amount to ulceration. Ulceration is also found in the later
stages of Lupus and Leprosy, usually when cutaneous lesions are present.

§ 128. Chronic Tnbercnloiis LaryngitiB should always be suspected when delicate
patients complain of constant hoarseness. This form of laryngitis is recognised by
(1) the general pallor of the mucous membrane, accompanied by a thickening or
swelling most marked over the arytenoids or the aryteno-epiglottic folds ; (2) the
occurrence of irregular, slowly growing ulcers, usually bilateral ; and (3) the history
or presence of pulmonary tuberculosis.

K 124^ 126 ] BEN ION NE W QRO WTHS 193

The Prognosis is always grave, and until rooently reooveiy when the larynx was
involved in tubeioulosis was piaotioally unknown. The course of the affection
depends more upon the condition of the lungs ({ 94) than that of the larynx.

The Treatment at first is largely constitutional — e,g,, creosote in doses of 1 to 5
minims is recommended. Locally, menthol, one part to five of olive oil, used as paint,
or an insufflation of menthol (8 grains) with iodoform and boraoic acid (of each
1 drachm), is valuable. When ulceration has occurred, after being swabbed with
cocaine and curetted, the parts should be thoroughly brushed with lactic acid, 10 to
60 per cent. This is a very favourite application. For the pain, which may be
severe enough to cause dysphagia, morphia (J grain), with starch (^ grain), may be
blown into the lar3mx ; or it may be sprayed with 10 per cent, cocaine. Dundas
Grant injects alcohol into the superior laryngeal nerve with excellent results.
Absolute rest from speech, a warm, dry climate, and sanatorium treatment, are
indicated (§ 94).

f 124. Ohronio Syphilitio Laryngitif. — ^The laryngitis accompanying secondary
syphilis may resemble simple catarrh, with the addition of whitish patches (§ 113).
But that which occurs in the later stages nearly always takes the form of ulceration.
The intensity of hyperemia, the irritability, and the profuseness of the purulent
discharge are features of syphilitic ulceration. It is distinguished from a tuberculous
ulceration by (1) the bright red coloration of the mucous membrane ; (2) the
presence of a deep, rapidly grotoing ulcer, with bright yellow surface, regular edges,
often undermined, sometimes unilateraL If the ulcers invade the upper surface of
the epiglottis, this is said to be pathognomonic of syphilis. (3) The presence of a
syphilitic history.

Prognosia and Treatment, — ^This form of laryngitis is twice as rapid as, and far
more destructive than, the preceding, and is liable to involve the cartilages (vide
Perichondritis). Even when arrested considerable stenosis may result. The usual
constitutional treatment must be carried out, full doses (60 to 100 grains) of potas-
sium iodide being given. Local applications of iodoform, or a spray of perchloride
of mercury (1 in 1,000), are employed.

III. Nodules and New Orowths. — Flat loccdised thickenings of the mucous
membrane are spoken of as toarts, nodes, or nodules. When they are peduncu-
lated they are spoken of as polypi. In either case they begin most frequently
CM a unilateral thickening on or near one of the vocal cords. In the early
stage they are extremely difficult to distinguish from syphilis or tuberde, and
sometimes tins can be accomplished only by the history. With one invportarU
exception [singer's node) nodules are unilatebal, and this feature of
cLsymmetry distinguishes them from the thickening which may result
from chronic laryngitis. The practical poirU of prime importance is the
distinction of benign from malignarU growths, often a task of considerable
difficulty.

S 125. Benign Kew Orowths begin most frequently as warts, nodules, or thickenings,
the surface of which is smooth, although congested. They may give rise to no sjrmp-
toms for a considerable time, unless they happen to be on the free edge of the cord.
Periiaps the commonest of these growths is what is known as a singer's node. This
lesion very often affects the under surface of the vocal cord, and hence may be over-
looked for a long time. It is distinguished from other nodules by its frequent involve-
ment of both sides symmetrically. A projection on one cord at the junction of the
anterior toith the middle third is probably a Singer's Wart ; one situated at the junc-
tion of the posterior with the middle third is probably pachydermia laryngis. In the
latter case there is a nipple on one cord which fits into a crater on the other. Paohy-
dennia Laryngis is a localised chronic laryngitis (§ 122), usually most marked over

104

THE UPPER RESPlBATOMt PA88A0E8

[ $$ 126, 129

tho vocal processes. Benign nodules, as a class, are differentiated from malignant
by the absence of pain and the paucity of symptoms of any kind. A pedunculated
benign growth (polypus) of the laiynz has the same clinical features, but is accom-
panied by very characteristic attacks of paroxysmal dyspnoea. Leprosy may affect
tho larynx. Benign growths often cause but little inconvenience. They aro
generally removable, without ulterior damage, by snaros or cutting forceps.

§ 126. Malignant Growths of the larynx occur chiefly in men. They may be divided
into two groups, extrinsic and intrinsic. The extri!%8ie variety start as thickenings of
the mucous membrane, which may resemble benign growths, or may be greyish-
white, or have a ragged suif ace. It rapidly passes on to ulceration, with hsemorriiage
and pain ; secondary enlargement of the glands follows. Death ensues unless the
larynx is extirpated early. Intrinsic cancer, on the other hand, is of slow growth and
low malignancy. It usually starts in the vocal cord, and causes a persistent huskiness.
Every case of persistent hoarseness occurring in men over middle age should be sent
to a laryngologist tor examination, llie operation of lar3mgo-fi8suro affords 80 per
cent, of cures in these cases if seen early. (See St. Clair Thompson, Med, Press,
February 21, 1912 ; and the Lancet, February 24, 1912.)

IV. Paralysis of the Tocal Cords can he detected only by carefully inspecting both the
POSITION and the mobility of the cords during (i.) rest, (ii.) phonation and (iii.) deep
inspiration.

§ 127. Paralysis of the Tooal Oords. — ^The chief actions of the larynx aro (i.) Abduc-
tion (glottis-opening), which is performed by the posterior crico-arytenoids, and
(ii.) Adduction (glottis-closing), which is performed by the lateral crico-arytenoids
and the arytenoideus muscle. The cords aro renderod tense by the orico-thyroids
(external tensors), and are relaxed and shortened by the thyro-arytenoids (internal
tensors — i.e., the muscle which lies in the vocal cord). The larynx is supplied by
two nerves, the superior laryngeal and the recurrent laryngeal branches of liie vagus.
The former supplies the crico-thyroid or tensor muscle and the mucous membrane
of the larynx, while the recurrent laryngeal supplies all the other muscles. In pro-
gressive lesions of the recurrent nerve the abductors are paralysed first, and later
on the adductors.

Table XI.

Nam$ of MuteU.

Crieo-thyroid
or external tentor.

Thvro-arytenoid
propritu^ internal tensor
in cord ittelf.

Posterior erieo-arytenoid.

Lateral crieo-arytenoid.

AryUnoideus,

Action,

Nerve Supply,

Superior
laryngeaL

Recurrent
laryngeal.

Superior laryngeal

and recurrent

laryngeal.

Phonation.

Respiration,

Tense and elon-
gate the vocal cords.

Adjusts edges of
the cords.

Close the glottis

(posterior third

chiefly).

Abduct — <.«., open
glottis.

Adduct — i,e,, close
glottis.

The Signs of Laryngeal Paralysis, — It is very rarely that a smgle muscle is paralysed ;
the paralysis nearly always affects a physiological group of muscles — i.e., the glottis-
openers (abductor paralysis) or glottis-closers (adductor paralysis) on one or both sides.

* Lateral thyro-arytenoid is the lateral part of this muscle.

il871

PABALYSia OF THB VOCAL C0BD3

196

FBralysiti la o!Um ocoonipaniod by more or Iobb oatnirh. which modiSos the appear-
ance Bomovliat, bat the evidences of laiyngeal paralysis depend upon the position
and mobility of the cords during phonation and mapiration. The symptoms are
given in Tabic XII.

Normally, during rest the cords am midway botwcon open and cloiiod (Fig. 60) ;
during phonation thoj aro approiimatod bo that practically no space is loft between
tJiem (Fig. 62) ; during deep inspiration they an widely oponod (Fig. 49a).

Fig. SI.— CADAVKEUO FUSITIUFI

high ii(

When tho cords are normal during phonation, but do not movo out on inspiration,
there is bilateral paralysis of the glottis -opener? — bilateral abd-uclor paralgtu (Fig. 63).
If both cords movo during phonation, but one of tham fails to move out fully during
inspiration, thont is anitalei-al abductor paralyaia (Fig. 54).

When tho cords neither move to the middle lino with attomptod phonation, nor
movo as far outwards as normal during deep inspirations, but lemain midway between
the two in the cadaveric position (Fig. 61), thore is loUU bilaleral paralyiia of adduatoia
and abductors (Fig. 56).

If diiring phonation and inspiration one coid remains immobile, there is tolat
unilateral paralyat».

Table XII. — Laryngeal Paralyses.
(From Gowers, sligbtly modified.)

Luion.

Sign,.

' Bilateral abdocter
1 (opener)
1 paralysis.

VolCT little fhansed : cough

long, and alt*Qd«d with loud
.trider.

Both cords near together; not
aepaiatcd during Iniptratlon, bnt
even drawn nearer together.

paralytit.

nflectlon of voice or cougli.

One cord near the middle line not
moving during inspiration, the othei

1 Total bilateral

No voice ; no cough ■. stridor

poslUonl.

psralfBla.

Voice low-pitched and hoarse ;
no cough: itildor abaent or

and motioulBM, the other moving
freely, and even beyond tho ndddle

Bilateral adductor
1 poriS^..'

No voice ; normal cough ; no
Btridot or dyspniea.

Cords normal in position, and

but not brought (ojether on an at-
tempt at phonatioD.

196 THE VPPBR RB8FIRAT0RY PA88AaB8 [(187

If thuiu isaphonia, andon l&iyngoscopio oxamination tincordedo not meet propeiiy
duimg attemptod phonation, ^though thoy move outw&tdB with inapiration, theio
is bSaUnd oddtKtor paralj/M (Figs. 56 and 57).'

The Eliology of laiyngeal paTaljses diffore coDsidorablf in the varioiu forms. Tbo;

may a

oonditioDS, bat each u so charactoriBtic thai

a bo readily identified. Thus hygtericid parah/iU is always double, and voiy

nearly always duo to adductor paralysis. Abductor paraJysia is generally — and if
Dnilat«nl is always — organic in origin. If the left vocal conl oaimot be abductod,
it is almost cortainly due lo pressure on the loft reoumat Uiyngeal, and this in oiuo
casoB out of ton is due to anevfytm of Oie aorla.
{a) BiLATBRAL Abductob Pabalysis (Fig. 63) may be duo to —

([.) The earlier stages of praeure upon both recurrent laryngeal nervos, aa by

mcdiastijial tumour, or poricardia] effusion (^ 54).
{ii.) Peripheral neuriUs from toxins (such as diphtheria, alooholism, inflaenxa),

certain drugs (t-g-. lead, arsonic), or simple catarrh.

(iii.) Central Causa, as in leeions affecting the medulla or base of the brain,

bulbar priatysis, cerebral tumours or syphilis, hsmorrfaage into the

bulb, tabos docsalis. disseminated sclerosis, meningeal conditions, etc.

(6) Unilatroai. Abddctob Paralysis (Fig. 54) is due to the same oauses acting

on one side only. Thus, if on the left side, it is duo in nine cases out of ten to aneurjwn

of the aorta, although no other signs of that condldon

may be present. Malignant tumourof the (esophagus

may also afloot the left recurrent laryngeaL Thickened

right pleura may be the cause of a paralysed right

locurront laiyngeol. Pressure upon the vagus in the

nock, as by an enlarged thyroid, or cervical glands.

may affect one or both sjdos.

(g) Totai. (Ab- and Addvctob) Bilatbbal Faba-

FlB. 6S.~BILATBBAL PABAITBIS "f"? '^'8- f ' ^, ??*"<»">" "'™^°' "^° .""Si"-

Of TBB QioTTiH-oPBNKM *>"' '* ™»y (raioly) be due to catorrii or hysteria. It
(BiLATEBAL Abdcqiob mav aiiss from any of the causes mentioned under
PABAiYBis). — TbB patient Bilateml Abductor Pamlysis, but is most frequently
y^^'S ^h^S^n h.V"^ of "tUrai origin. It occurs lator in the disease than
cordi <lo noi man mawardi abductor paralysis, the abductor fibres m the nerve
diaiBt iap inipiiatim (u being the first to be affected.

'"■raTiiSiTa ****' a. '■*' T:'^'^ (Ab- and Adductoe) Umutkbal Paba-
tli8 above liK^^^ne* LYSIS is due to the same causes as mentioned under
prodnwd by acute larrngesl unilateral abductor paralysis — i.e., usually preBsuie
oatairh, but the cordj would upon the recurrent laiyngoaL This oonditbn, how-
be pink iostel el white. ^^ ^^^ ^t ^ Uter stoge in the oa«., unilateral
abductor paralysis being a feature of the earlier stage-
Total paralysis is soaoUmos calked " recurrent paralysis," because it is due to
paralysis of the recurrent laryngeal.

(c) BiLATEBAL Addcctob Pabalysis (Figs. 66 and 67) is always fututional (vii.,
univnnected with gross letiotu) : (1) hystfliical ; (2) simple catarrii, or overuse of the
voice ; (3) general weakness, as in amemia. But the first of those is by far the most

Prognwis. — Laryngeal paralysis is generally only a minor element in the ease-
When ooouiring alone, however, the prognosis in adductor paralyos is good, because
it is always of functional origin. Paralysis arising from syphilis is remediable if
truated early. In all forms, however, the prognosis depends upon whether the cause

Treatmtnl. — Hysterical paralysis should be treated on linos laid down olsowhero-
Strong faradisation or static electricity to the laryni is indicated, the patient being
instnictod to call out loudly. In oiganie paralyses the prognosis depends upon the

' Further particulara of the actions of the various muscles may be found in a study
of laryngeal paralyses since the introduction of the laryngoscope, by Sir Fclis Semon
Brain, 1882. vol iv.. p. 471).

§1«8]

NERVOUS GROUP

197

oause. Potassium iodide should reoeiye a fair triaL Stryohnine and eleotrioity are
usefuL In organic oases, if dyspnooa be severe, tracheotomy must be performed.

Illttstbations of Labykgeal Paralysis. — It should be rememberod, in studying
these illustrations, that to test the motor power of the vocal cords it is necessary to
make the patient nrspraE deeply to opbk the cords, then to phonatb, so as to close
the cords, for a given position of the oords conveys no information unless it is first
known which of these acts the patient is performing.

In laryngeal paralysis it is very important to decide whether a functional or organic
cause is in operation, and the following hints should be remembered :

1. Glottis-closer (adductor) paralysis is generally functional; glottis-Opener

(abductor) paralysis generally Organic.

2. Bilateral paralysis is generally functional; One-sided paralysis is generally

Organic.

3. Left Abductor (glottis-opener) paralysis suggests Aneurysm.

Fig. 64. — ^Lbfp Abduotob, or glottts-
opener, paralysis. — Dubinq in-
SPIBATIOIT the left cord remalni
fixed. Instead of moving oatwarda
like the right cord does. This
occurs in early paralysis of the
recurrent lanmgeal nerve of ob-
GANio OBIQIN — e.(f., aneorysm.

Fig. 65. — ^TOTAL BiLATBBAL paialysis.

— DT7BING INSPnUTION and DX7BIN0

PBONATION both cordt are immo-
bile, and remain in what is prac-
tically the cadaveric position.
Nearly always of obqanio origin,
and frequently central.

Fig. 56. Fig. 67.

Figs. 66 and 67. — Pabtial Bilatbbal Adduotob, or glottis-closer, paralysis. — It
is the condition commonly met with in hysterical or fxtnctional aphonia.
DUBINO PHONATION the cords close anteriorly and posteriorly, bat leave an
elliptical space between them. The glottis is closed by two muscles — ^the crico-
thyroid in front, and the arytenoideus b^nd. If the obico-tbyboid is mainly
affected, the condition depicted in Fig. 66 is seen, and it is met with in functional
aphonia and exhaustion. The abytbnoidevs closes the posterior angle, and
wtien this is paralysed the posterior angle remains open (Fig. 57). Both of these |
forms are met with in acute and chronic laryngitis, and are generally independent of |
any actual nerve lesion, excepting perhaps p^pheral neuritis and some rare cases
due to a local lesion affecting the recurrent laryngeal nerve of both sides. /

V. Spasm of the Laryngeal Muscles and consequent Inspiratory
Dyspncba, is not a very common occurrence, except in the form of Laryn-
gismus Stridfdus, a disease almost confined to childhood. It may arise when
a foreign body fosses into the larynx, and may ooiasionally occur in aduUs
who are thz subjects of acute laryngitis. Inspiratory dyspnoea may also arise
in Bilateral Abductor Paralysis,

§ 128. Larynsfisaps Stridulus or Nervous Croup^ is a form of paroxysmal
inspiratory dyspncBa. It consists of a sudden spasmodic closure of the

^ Synonyms : Spasmus glottidis, spasmodic croup, child-crowing, spasm of the
larynx.

198 THE UPPER RESPIRATORY PASSAGES [§188

glottis, followed by a long noisy inspiration whicli produces a crowing
sound, and is due to spasm of the adductors. It is a nervous affection,
and appears to be due to some irritation of the vagus or of its recurrent
laryngeal branch. The whole attack lasts from a few seconds to a minute
or two. The child may become cyanosedor the spasms may spread to
other muscles and give rise to general convulsions. Occasionally it ter-
minates fatally. The attacks come on either during sleep, or in the
waking state. They are very apt to recur, and the severity of the attacks
may increase at each recurrence. On the other hand, if the attacks are
slight, they may gradually disappear as the child grows older. In the
intervals the child is free from cough or hoarseness, and the larynx appears
healthy.

The Etiology is obscure. It is practically confined to children of from
four months to two years old, and nine-tenths of these are rachitic — that
is to say, children in whom infantile convulsions and tetany are also apt
to arise. It is twice as common in boys. It is more frequent in the
spring time, and it is often hereditary. In older subjects laryngeal spasm
and inspiratory dyspnoea occur sometimes in tabes dorsalis, when it forms
the laryngeal crisis of that disease. Its rarer causes are epilepsy, hysteria,
tetany, chorea, reflex irritation of the vagus or its recurrent laryngeal
branch from mediastinal growths, a growth or foreign body in the larynx,
or too long a uvula.

The Diagnosis is not difficult, though it is well to bear in mind the
possibility of a foreign body in the throat, larynx, or trachea. There are,
however, three pathological conditions to which the term "croup" is
loosely applied and which are also characterised by a paroxysmal

INSPIRATORY DY8PN(EA.

1. Laryngismus stridulus is the non-inflammatory nervous affection
described above. This is recognised by the absence of cough, hoarseness
and other symptoms referable to the larynx in the intervals between the
attacks. There is often a history of similar attacks.

2. Catarrhal Laryngitis (laryngitis stridulosa, false croup) is often
associated with attacks of dyspnoea, coming on usually at night in
children under ten who are suffering from cough and hoarseness during
the day. It may last for an hour or so. This is due to the collection of
thick secretion, or to the sticking together of the edges of the glottis from
slight laryngeal catarrh (§ 121).

3. Membranous Croup, or laryngeal diphtheria. — This is true diph-
theria, and is attended by the constitutional and other symptoms of that
disease (Chapter XV.). However, some {e.g., Whitla and others) maintain
that a non-diphtheritic membranous croup may occur. A severe injury
le,g,y drinking out of a boiling kettle) may certainly result in a membranous
or " diphtheritic " inflammation of the mucous membrane.

Treatment of Laryngismus Stridulus. — (a) For the Attacks, — In severe cases
cold water may be dashed in the face, or the patient plimged into a hot
bath, or alternately hot and cold, or cold water douches applied. In-

§129] PHYSICAL EXAMINATION OF THE NOSE 199

halation of chloroform or ether relieves it promptly. Artificial respiration
is often of great service, and it may restore, even after apparent death. In
the rare cases in which the spasm is prolonged and continuous, tracheotomy
may be necessary. Mild cases require no treatment except rest and
warmth.

{h) For the Intervals, — The patient should be kept very quiet, and irrita-
tion of the surface or the application of any stimuli conducive to an attack
should be avoided. Reflex causes of irritation should be sought in the
gums (e.^., teething), in alimentary canal (e,g,, worms or gastric disorder),
in the lungs and elsewhere (vide causes). The general treatment of rickets
should be adopted, and it is worth bearing in mind that children taken
into the country very often cease to have these attacks. Sponging with
cold water twice or three times a day is of value ; and as to medicine,
bromides and chloral in small doses allay the irritability of the nervous
system, on which the condition mainly depends. Faradisation of the
pneumogastric is sometimes useful.

VI. and YII. DiseaMB of the Pharynx (ante) and of the Nose (post)
are generally attended by a certain amount of hoarseness and alteration of the
voice. The latter give to the voice a peculiar nasal twang, which is very
characteristic.

The Nasal Cavities.

§ 129. Symptoms and Physical Examination. — ^Diseases of the nose will
be considered under three cardinal symptoms : Inodorous discharge from
the nose (Rhinorrhoea) ; foul discharge from the nose (Ozsena) ; mouth-
breathing and snoring (Obstruction of one or both Nostrils). Bleeding
from the nose also occurs in some nasal disorders, but it is no^ a cardinal
symptom. It is perhaps more generally associated with some constitu-
tional or general derangement. Sneezing, ticUing in the nose and sniping
may also be present ; and the quality of the voice may be altered, particu-
larly in nasal obstruction. The sense of smM is always disturbed to some
extent in nasal disorders. In some instances, headache, vertigo, and
other nervous derangements are met with in association with disorders of
the nose, especially when the free transit of air through the nasal passages
is interfered with, and the atmospheric pressure within the tympanum
disturbed.^ Various constitutional symptoms may result from septic
conditions of the nose or the adjacent sinuses, and not infrequently a
patient suffers from listlessness and general debility for a long time before
our attention is directed to the true source of his troubles.

CBnioal Investigation. — ^Rhinoscopy or examination of the nose may be
effected through the anterior nares (anterior rhinoscopy), and the posterior
nares (posterior rhinoscopy) ; and by digital examination posteriorly.

^ A notable instance in my own experience was that of a lady of thirty-five who
suffered from the most troublesome tinnitus aurium and occasional giddiness, which
was not relieved until the middle turbinate bone was removed by Dr. Soanes Spioer
(see the Author's ** Clinioal Lectures on Neurasthenia/* fourth edition).

200 THB UPPER RESPIRATORY PASSAGES [ § 129

Antebior Rhinoscopy. — ^First examine the anterior nares for any
obvious disorder, such as fissures, ulcers, scars from ulcers, any narrowing
of the nares, or a deviation of the septum ; secondly, introduce a speculum
(Fig. 58), using either a direct light or one reflected from a mirror on the
forehead, as in lar3aigoscopy. In this way an examination of the inferior
turbinate bone can be made, to see if it be hypertrophied. The inferior

or middle meatus can be thus examined for polypi or
alteration in the mucous membrane. If, as frequently
happens, the anterior part of the inferior turbinate is
hypertr<^hied, and hides the view, this may be reduced by
swabbing out with a cotton-wool pledget soaked in a 10 per
cent, solution of cocaine.
^^spEOTOot?.^ Posterior Rhinoscopy is effected by precisely the same

procedure as in laryngoscopy (§ 119), using the smallest of
the mirrors, and turning it upwards. It is convenient to have a special
mirror for this purpose mounted on a curved handle, the stem being
hinged at its extremity, so that it can be raised to any desired angle. It
is important to avoid touching either the dorsum of the tongue or the
posterior wall of the pharjmx. The patient should be instructed to breathe
gently all the while through the nose. By moving the mirror slightly in
different directions we are able to examine the posterior nares and
turbinated bones, the inner end of the Eustachian tube for any swelling,
and Luschka's tonsil {cf. Fig. 48). The pharyngeal or Luschka's tonsil is
a mass of lymphoid tissue on the pharyngeal roof and posterior wall above
and between the Eustachian tubes ; when in a condition of hyperplasia it
forms the cushion-like growth of post-nasal adenoids (§ 109).

A great deal of information may be derived by passing the finger behind
the soft palate, but for this purpose it is generally necessary to spray the
pharynx with cocaine (10 per cent.).

Our first inquiries concerning any given case of suspected disease of
the nose should be relative to the leading symptom, especially whether
there be any nasal discharge, and whether it is inodorous or foul smelling.
We cannot depend upon the patient's statement on this point, because
very often the same disease which causes a foul discharge may blunt the
sense of smell. Secondly, we must investigate the history, and whether
any of the other sjonptoms above mentioned were present. Thirdly, we
must proceed to the physical examination by testing whether the
patient can breathe freely through each nostril separately ; by examining
the anterior, and, if necessary, the posterior nares.

Classification. — ^Diseases of the nose, like those of the throat, are best
classified by the physical signs met with on examination — ^viz., nasal
discharge, nasal obstmciion, epistazis— and their causes.

(a) Acute Inodobous Discharges (Acute Rhinorrhcea) — the causes
of which are —

I. Acute Rhinitis; II. Syphilis (snuffles); III. Diphtheria, and other fevers;
IV. Coryza ; V. Hay Fever ; VI. Glanders.

§180] ACUTE IN0D0B0U8 DI8CHARQE FROM NOSE 201

(6) Chronic Inodorous Discharges (Chronic Rhinorrhoea) — ^the
causes of which are —

I. Ghronio Simple Bhinitis ; II. Chronio Hypertrophic Bhinitis ; III. Cerebro-
spinal Bhinorrhoea ; IV. Ulcerations of the Nose, Polypi, and occasionally
OEktarrh of the Sinuses.

I. Ulcerations and Bone Disease — Syphilis, Tubercle, and Lupus ; II. Atrophic
Bhinitis ; III. Empyema of Antrum and other Sinuses ; IV. New growths
and x)ol3rpi breaking down, and impacted foreign body.

(d) Nasal Obstruction (Snoring and mouth-breathing) — the causes of
which are —

L Pharyngeal Adenoids ; II. Polypi ; III. Deviated Septum ; IV. Hypertrophy
of Turbinate ; and V. Foreign body and neoplasms in adjacent parts.

(e) Epistaxis, the causes of which may be Local or General.

§ 190. Acute (or recent) InodorouB Discharge from the Nose (Rhinor-
rhoea). — Discharge is afreqiient symptom when disease of the nose is present,
and we should endeavour to ascertain if this he odourless or offensive, although
these are, of course, only r dative terms, athd the two groups cannot be sharply
defined. Among the causes of Acute Inodorous Discharge, cor^enital
Syphilis should he suspected in infancy ; Diphtheria in childhood ; Coryza
in aduUs,

I. Acute Rhinitis may be set up by irritation of any kind, as the vapour
or dust of some trade, or by any injury. For instance, a profuse discharge
from one nostril in a child should always make us suspicious of his having
inserted a pea, marble, or other foreign hody, although the history may be
wanting. But its commonest cause is a " cold " (see Acute Coryza below).

II. ^* The Snuffles." — ^In infants a few weeks old, congenital syphilis is
almost invariable attended by a profuse nasal catarrh, and is known
familiarly as the " Snuffles." The other features of nasal syphilis will be
referred to under Ulcerations.

in. Diphtheria and other fevers. A profuse nasal discharge excoriating
the upper lip, with slight elevation of temperature, and prostration, coming
on suddenly in a child or young person previously healthy, is so character-
istic of diphtheria that the disease may almost be diagnosed from these
features alone.

rV. In Acute Coryza, " catarrh,** or " cold in the head/' there is profuse
muco-purulent discharge attended by sneezing, running from the eyes
and febrile symptoms with frontal headache, extending over a few days.
It is usually attributed to some exposure to cold (" a chill ") ; but it fre-
quently prevails in an epidemic form, and is then of microbic origin. It is
predisposed to by cold and damp weather, by adenoids, and the other
causes of chronic rhinitis. It is not a serious disorder, but its repeated
occurrence may lead to middle-ear catarrh, or to bronchitis by extension.

Treatment of " CatarrhJ*^ — In severe cases it is advisable for the patient
to keep in bed. At the outset a full dose of Dover's powder given at night,

202 THE UPPER RE8P1BAT0BY PASSAGES [§1S1

or a mixture of tr. aconiti TTl^i., liquor ammonisB acetatis, with other salines,
every two hours, may cut short the disease. Locally, sprays of cocaine
(2 to 4 per cent., applied with caution, occasionally), or equal parts of
boracic acid and borax dissolved in water, or camphor and menthol (gr. 8
to 5i. of paroleine), may abort the disease. Ferrier's snuff ^ is also useful.
Inhalations of camphor, menthol, or vinegar taken at night are reputed
to be efficacious. Vaccines are efficacious in some cases.

V. Hay Fever, or, as it is sometimes called. Hay Asthma, is a severe catarrh of the
nasal mucous membrane and conjunctivse. coming on fairly regularly in the summer
or autumn of each year, presumably connected with the inhalation of the pollen of
flowers. It is accompanied by the symptoms of severe coryza, just described, which
come on somewhat suddenly in a person predisposed, who has been outdoors (usually
in the hay-making season), and are attended by a certain amount of constitutional
disturbance. There appear to be two clinical varieties of this disease — (L) where the
symptoms are chiefly constitutional ; and (ii.) where the symptoms are chiefly local.
In the latter there is generally hypertrophy of the inferior turbinate, which constitutes
an important predisposing factor.

The Etiology of this disease is somewhat obscure, but it evidently is connected in
some way with pollen, especially that of grasses. There are some people, usually
those with a marked neurotic taint, who cannot go within a couple of miles of a hay-
field in the summer without developing the disease. It is diagnosed from simple
coiyza chiefly by its seasonal occurrence. It resembles asthma in some respects,
especially in its periodicity, but differs in that the nasal, instead of the bronchial,
mucous membrane is involved. The malady is not a fatal one, but causes serious
discomfort and inconvenience. Sometimes people get rid of it as they get older,
but in others it continues throughout life.

Treatment, — ^The first indication is the avoidance of the cause. This may be accom-
plished by a sea- voyage, residence at the seaside at a high altitude, or by living indoors
in the city, taking care that no plants or flowers enter the house. But there is no rule
in this respect ; for some do better at a high altitude, others at a low one ; some get
better at the seaside, others in a town. Quinine, arsenic, iron, or belladonna, may
be taken before the attack is expected. Antipyrin (15 grains) has been credited with
cutting short an attack. If the disease extends to the bronchi, asthma papers and
cigarettes should be employed. Locally, means should be taken to prevent the pollen
reaching the mucous membrane. For this purpose Brunton recommends smearing
the nostrils with zinc oxide ointment, which not only allays the irritation, but, by
remaining longer unmelted, is more efficacious than other ointments. Antiseptic sprays
destroy the pollen. Of these quinine, J grain to the ounce, dissolved in normal saline
solution, as being less irritating than water, gives good results. Sir Andrew Clark
recommended swabbing out with hyd. perchlor., gr. i. ; quin. hydrochlor., gr. iL ;
glyc. ac. carbol., ^i. To relieve the discomfort, cocaine tabloids (J grain), inserted
in the nose, sprays of cocaine (4 per cent.), or menthol (20 per cent.) are used. The
mucous membrane, if thickened, must be treated as in hypertrophic rhinitis. Pollan-
tin has been greatly recommended.

VI. Glandeii. — ^The copious discharge of viscid semi-purulent matter from the nos-
trils is one of the earliest symptoms of Farcy, or Chronic Glanders (§ 362).

Vn. Kyiafis is chiefly met with in tropical countries. It is due to the presence of
maggots. The eggs from which they hatch are laid by a fly on the nasal mucous
membrane, usually while the patient is asleep. Inhalation or local application of
pure chloroform is the usual remedy, but insufflations of calomel are also successful.

§ 18L In Chronic Nasal Discharges it is stUl more diffljuU to draw the
line between odorous and inodorous discharges, since many of the conditionSy
though odourless at the outset, become offensive later on, and it will generally
be necessary to pass in review all the conditions mentioned in this section

^ Bismuth Subnitrate, 5vi. ; Morph. Hydrochlor., gr. ii. ; Pulv. Acao., 3u«

§ lai ] GHRONIO NASAL DISCHARGES 203

and § 132 below. The following are the chief causes of inodorous

DISOHABGE :

I. Chronic Rhinitis is a chronic inflammatory condition of the mucous
membrane of the nose, attended by increased secretion, and usually by
thickening. It occurs in three forms : (a) Simple ; (6) Hypertrophic
(infra) ; (c) Atrophic (§ 132). The first two give rise to an inodorous,
but the ATROPHIC to an odorous discharge.

Chronic Simple Rhinitis consists of a chronic congested, and some-
times, later on, a hypertrophied state of the mucous lining of the nose,
attended by a continuous mucous or muco-purulent discharge. There
is generally a certain amount of nasal obstruction, giving rise to altered
voice and snoring.

Etiology, — (i.) It is predisposed to by cardiac and pulmonary disease,
alcoholism, and the strumous diathesis. It may be determined by (ii.) re-
current attacks of neglected coryza over a long period of time ; (iii.) the
injury caused by an unsuspected foreign body, in which case the con-
dition is generally confined to one. side ; or (iv.) the constant irritation of
dust and noxious vapours — e.gr., in masons, fustian-cutters, (v.) It is often
associated with adenoids, enlarged tonsils, and other causes of obstruction
to the nasal respiration.

Prognosis. — The disease is chronic, and requires prolonged treatment.
The chief fear is that middle-ear catarrh may result from the extension
of the inflammation up the Eustachian tube. Even apart from this, it
is very important to treat these cases in strumous children, because the
condition interferes with the respiratory functions of the body.

Treatment, — ^In the early stages alkaline washes — bicarbonate of sodium,
gr. XV., and borax, gr. v., or carbolic acid, gr. iii. to 5i. — sniffed up or given
by the nasal douche. This is followed later on by a spray of menthol and
eucalyptol (gr. xxx. to Ji. of aquol or paroleine), or an ointment of cocaine
and thjrmol (gr. x. to $i. of white vaseline), or by the use of the ammonium
chloride inhaler. Constitutional treatment is necessary, by means of
tonics, cod-liver oil, and malt. Alcohol should be avoided, and a high
and dry climate should be sought. In the later stages, the only satisfac-
tory method of treatment is applying chromic acid (gr. v. or x. to 5i-)»
or, still better, the galvano-cautery.

II. Chronic Hypertrophic Rhinitis is a special form distinguished from

the preceding by the fact that there is considerable hyperplasia of the

nasal mucous membrane, especially over the inferior turbinate bone at

its anterior and posterior ends. It presents the same symptoms as the

preceding, but in a greater degree. Even in slight cases it is apt to be

accompanied by headache and mental depression. It is frequently asso-

cated with adenoids. The Prognosis is on the whole less favourable.

The Treatm,ent is much the same, but more active measures are indicated,

and especially treatment by the thermo-cautery.

in. Oerebro-spinal Bhinorrhoda is a oontinual dripping of a watery, dear fluid
(cerebro-spinal fluid) from the nose, due to the formation after injury or disease of
a communioation between the nasal cavity and the sub-arachnoid space. The fluid

204 THE UPPER RESPIRATORY PASSAGES [§182

passes through the cribriform plate of the ethmoid. Its nature is at once recognised
by the fact that it reduces Fehling^s solution. Little can be done for the condition ;
inteiference is apt to be followed by meningitis. The flow sometimes ceases spon-
taneously. Some cases have been successfully treated by applying to the nasal mucosa
irritants which cause swelling and occlusion of the lumen of the sinus.

IV. Ulcerations of the Koie, Polypi, Dtfease of the Sinmef, occasionally produce
inodorous discharges, but the discharge is more often offensive (see below). Chbonic
Frontal Sinus Empyema is, however, attended by (i.) a purulent, non-fatid nasal
discharge, (ii.) frontal or supra-orbital headache or feelings of discomfort, and (iii.) more
or less well-marked nasal obstruction, caused by inflammatory enlargement of the
middle turbinated body, or by pol3rpi. Headache only occurs from retention, and not
when drainage is free. There may be tenderness on pressure over the affected side.

V. Post-nasal Oatarrh is a condition in which the catarrhal processes are confined
to the naso-pharynx. Its importance is derived from the fact that it is not easily
recognised unless looked for. The constant swallowing and absorption of septic
matter from the post-nasal focus may give rise to serious constitutional results, and
by direct extension the ear or sinuses may be affected. Treatment is on the same
lines as that for the commoner forms of nasal oatarrh.

§ 182. Ozeena or a Chronio Offensive Discharge /rom the nose may occur
in the later stages of many of the conditions mentioned in the preceding
section. But the chief causes of foul discharge from the nose are as follows ;
the commonest and fouUest occurring in atrophic rhinitis in the young ;
SYPHiLiTio DISEASE in middle life ; and cancer in the aged.

Foreign bodies (which have already been referred to) athd Polypi, both of
which may cause one-sided ozcena, wQl be described under Nasal Obstruction
( § 133) which is their leading symptom. It wiU be necessary to give some
detailed account o/^— Ulcerations and Bone disease ; Atrophic Rhinitis ;
and Empyema of the Sinuses.

I.' Ulcerations and Bone Disease attacking the nose are mostly of syphil-
itic, occasionally of tuberculous, origin. Neoplasms in the later stages
ulcerate, but in the earlier stages give rise to Rhinitis or Nasal Obstruction
(§ 133).

(a) Syphilitic Rhinitis. — In the early stages of sjrphilitic infection we
may get an acute catarrh with superficial ulceration, which is the condition
found in children with congenital syphilis, known as " snuffles." In the
later stages gummata form in various situations, which rapidly involve
the bone and other parts; the discharge then becomes very foul. The
ulcers have the same character as those affecting the throat (g.v.).

(6) Tubercnloiis Ulceration more often involves that part of the nose near the
orifice, but otherwise the ulcers much resemble the preceding. They are difFerentiated
from them by their very much slower progress, as well as by their site. The bones are
rarely attacked, and consequently the discharge may be more or less inodorous ;
and there is rarely the falling in of the bridge of the nose, which so frequently occurs
in tertiary syphilis. The ulceration of Lupus differs but little from the true tuber-
culous ulceration, except that lupus vulgaris usually involves also the skin of the alse
nasi, wTience ii has probably spread.

Atrophic rhinitis is distinguished from these ulcerations by the pallor
and thinning of the mucous membrane, the absence of visible ulcers, and
the absence of a history of evidences of syphilis or tubercle respectively.

The Prognosis of nasal ulceration is fairly good if the patient come
imder treatment early, but if not it leads to considerable destruction of

§ 182 ] OZMNA 205

tissue. Tuberculous ulceration may slowly lead to the destruction of the
oUb of the nose, but syphilis results in the most extensive destruction of
the hones both of the septum and the palate ; the bridge of the nose falls
in, and the.anterior nares may be represented by a single gaping orifice.
It is this extensive and rapid destruction which is so pathognomonic of
nasal syphilis.

The Treatment should be much more prompt and vigorous in ulceration
of the nose than in chronic rhinitis and similar affections, because of the
destruction which ensues. Carbolic and astringent sprays are useful
palliatives, but surgical measures are called for if the bone is involved.
All dead bone must be removed. Tuberculous ulcers be scraped. Large
doses of potassium iodide lead to rapid healing of syphilitic ulcerations.

IL Atrophic Bhinitif > also known as idiopathic or true ozsoa, is characterised by
(i.) a thick, foul discharge, which is sometimes profuse, sometimes scanty ; (ii.) the
nasal cavities are often large, and the bridge of the nose broad and sometimes depressed.
The mucous membrane is thin, pale, and covered with crusts, hard, adherent, and de-
composing. Sometimes it is unilateral — e.^., in cases of deviated septum. A certain
amount of chronic pharyngitis is usually present, (iii.) The breath has a foul odour,
which is not detected by the patient, as the sense of smell is blunted. It is Diagnosed
from the other causes of ozsBna by the absence of ulceration, the presence of atrophied
mucous membranes, and wide cavities.

Etiology, — (L) It is commoner in the young and in women. It usually starts before
sixteen years of age. (ii.) Unilateral atrophic rhinitis is mostly due to some local
cause, such as deviated septum or sinus disease, the narrower side being healthy,
(iii.) The exciting causes of bilateral atrophic rhinitis are obscure : it has been said
to follow chronic rhinitis in strumous children ; (iv.) in some cases it is a sequence of
hypertrophic rhinitis.

Prognosis, — Prolonged treatment is necessary for its cure, and even this is not very
hopeful if the disease be advanced. The disorder is generally most marked at about
twenty years of age ; it becomes less troublesome at middle age, and, as it gradually dis-
appears with advancing years, we may presume that it tends slowly to spontaneous cure.

TreaknenL — Alkaline and antiseptic douches and sprays are indicated, as in § 131.
To stimulate the mucous membrane, nasal tampons of cotton wool, soaked in glycerine,
are used. These aro useful in unilateral rhinitis, as they insure respiration through
the narrower cavity. The nose may be swabbed out with silver nitrate (10 grains to
the ounce), or with trichloracetic acid (5 to 20 parts in 1,000), which removes the smell.
Constitutional treatment is also advisable. Vaccines may assist.

in. Ohronio Empyema of the Antrum and other sinuses is a term applied to a
chronic suppurative inflammation of the lining membrane, though the term '* em-
pyema " should be reserved for cases in which there ib retention. The most constant
and cardinal symptom is a purulent or sero-purulent discharge from one nostril, which
is generally offensive or sickly. It may arise as an extension of nasal catarrh, or
various suppurative nasal conditions (syphilis), tubercle, bone disease, etc.

Empyema of the Antrum may be due to irritation from a tooth. Many of the patients
have had deoistyed teeth in the upper jaw. It is recognised by the discharge being
intermittent, returning usually about the same time each day, and flowing freely when
the head lies on the opposite side, or is lowered between the knees. The discharge
may be seen coming from beneath the middle turbinate. If a bright light is held in
the mouth, the cheek of the affected side remains darker than the other (trans-illumina-
tion).

Discharge from the frontal or anterior ethmoidal sinuses flows best when the patient
is upright. It comes from under the middle turbinate, and there is often pain in the
brow and orbit (see also p. 204).

Discharge from the posterior ethmoidal and sphenoidal sinuses flows over the middle
turbinate and down into the pharynx. There may be exophthalmos, ptosis, stra>
bismus, etc., with disease in this locality.

206 THE UPPER RESPIRATORY PASSAGES [§188

Various constitutional symptoms are recognised as being associated with sinus
disease, due probably to the toxaemia which results from septic absorption. Lassi-
tude, headache, occasional elevations of temperature, and numerous nervous and
va80*motor symptoms are amongst the commonest. They generally present a periodic
or paroxysmal character. Trifacial neuralgia may also result from sinus disease. If
overlooked or neglected, empyema may excite middle-ear catarrh (with tinnitus,
deafness, etc.), recurrent nasal catarrh, and nasal polypi.

Prognosis and Treatment. — Sinus empyoma is chronic and intractable, but very
rarely fatal. The treatment is based on surgical principles, but the chief indications
are free drainage and stimulation of the chronic inflammation until it takes on a more
healthy action of repair.

IV. Neoplasms and Polypi (§ 133), and Impacted Foreign Body (§ 130, 1.), are referred
to elsewhere.

§ 133. Nasal Obstruction, Snoring, and Mouth-breathing. — 'S'asal obstruc-
tion may be ^partial or complete, and it may exist on one or both sides. It is
met with in a greater or less degree in nearly all of the various nasal conditions
previously discussed, and it is a marked feature in Hypertrophic Rhinitis
(p. 203). Its commonest cause in children is Pharyngeal Adenoids
(§ 109). It is also a cardinal symptom in Nasal Polypi, Devution or
Spur op the Septum, Alar Collapse, Foreign Bodies, Neoplasms,
ar^ Abscesses.

Effects, — Apart from the inconvenience of snoring, nasal obstruction
renders the individual prone to pharyngitis, stomatitis, bronchial catarrh,
and other consequences due to the entry of cold air into the lungs without
being properly warmed by its passage through the nose. Among the
other consequences are a nasal quality of the voice, distortion of the chest
(when arising early in life), and impeded respiratory functions of the body
generally. These disorders consequently assume an importance quite
out of proportion to the degree of local mischief.

I. Pharyngeal Adenoids are of very frequent occurrence. They con-
stitute one of the forms of granular pharyngitis, and the disease has been
referred to under that condition (§ 109). It is the most frequent cause
of mouth-breathing and snoring in children. It is often overlooked by
parents, a circumstance greatly to be regretted for three reasons. In the
first place, it is one of the most potent causes of chronic otitis media and
deafness in after-life ; secondly, it impairs the respiratory functions of the
body, as just mentioned ; and thirdly, the open mouth and vacant aspect,
which are so characteristic, produce an appearance of backward intelli-
gence which in point of fact often results.

II. Polsrpi, or pedunculated tumours, are the most frequent new growths
in the nose. Polypi are of three kinds : (a) Gelatinous ; (6) Fibrous ;
and (c) Malignant.

(a) Gelatinous or Mucous Polypi are the most common form of
polypi. They usually consist of myxomatous tissue, believed by some to
be associated with inflammatory disease of the subjacent bone. They are
often multiple, and most often grow from the muco-periosteum of the
upper and middle turbinated bones. Their detection is not difficult, for
in addition to the feeling of " stuffiness " and the watery discharge (which

{ ia4 ] NASAL OBSTRUCTION— EP18TAXI8 207

may be intermittent), they are easily seen through the nasal speculum as
pale grey glistening bodies. They are apt to recur after removal, but are
not malignant in other respects.

(b) Fibrous Polypi grow from the roof of the naso-pharynx. By their
growth they displace the parts around and are apt to give rise to ** frog
face." The discharge is often foul, and may be heemorrhagic. They
sometimes become malignant (fibro-sarcoma). They may occur at any age.

(c) Malignant Polypi may be either fibro-sarcomatous or carcino-
matous. They are known by their rapid growth, and the resulting de-
formity of the face, " frog-face," and by the offensive and haemorrhagic
discharge. Sarcomatous growths are chiefly met with in the young ;
carcinomatous in the aged.

Prognosis and Treatment, — The benign poljrpi are not dangerous to life,
but are liable to recur. Malignant growths give rise to a condition of
considerable gravity. Occasionally fibrous tumours atrophy. Gelatinous
polypi, arising as they do from the anterior part of the cavity, can generally
be removed by means of a nasal snare or forceps ; but the other varieties,
springing usually from the posterior parts and infiltrating the tissues
around, may require an operation of some magnitude.

m. DefUted Septam and Hasal Spar. — The nasal septum is rarely quite in the
median line, but the displacement is often considerable. Sometimes it results from
injuiy. Various consequences may ensue, such as hypertrophied turbinate on ono
side, atrophic rhinitis on the other. When an angle is formed in the septum nasi, it
is spoken of as a '* spur," and this is most readily dealt with by the surgeon.

IV. Hypertrophied Tnrbinate is met with usually either as part of, or a consequence
of, chronic hypertrophic rhinitis. It may occur on one or both sides, and in either
case, in narrow nostrils, produces partial obstruction, snoring, and mouth- breathing.
It is removable by turbinectomy ; sometimes the thermo-cautery is employed (see
Hypertrophic Rhinitis, p. 203).

V. Foreign Bodies within the noae, Heoplaf mi, and Absceieei in adjacent parts may
also produce unilateral nasal obstruction.

§ 184. EidstaziB (bleeding from the nose) may bo a symptom of nasal
disorders, but if in any appreciable quantity it is usually an evidence of
some general disorder. Not infrequently both general and local causes
are in operation, and the nasal cavities should alvoays he carefully examined.
The bloodvesseb give way in this situation (sometimes as a kind of safety
valve) merely because they are thin- walled, numerous, and near the sur-
face. So much is this the case that the diminished atmospheric pressure
to which mountaineers are subjected is sufficient to produce nose bleeding
when they reach great heights. The Causes may be divided into two
groups — ^Local and Constitutional.

(a) Local Causes, in which the haemorrhage consists usually of little
more than streaks, may arise from any marked congestion of the mucous
membranes, such as that which accompanies adenoids, acute rhinitis,
worms in the nose ;^ or as a consequence of mechanical violence, applied

^ Dr. Manasseh relates the case of a child with epistaxis in whom a leech was found
in the nose. This had gained entrance by the child drinking at springs in a district
where leeches abounded in the water. — Lancet, September 16, 1899, p. 785.

208 THE UPPER RESPIRATORY PASSAGES [ § 184

either directly to the nose or to the base of the skiill. Any serious destruc-
tive disorder — such as new growths, especially malignant, syphilitic,
tuberculous, or other ulcerations (which if small are very apt to be over-
looked)— ^may be attended by a certain amount of recurrent bleeding. In
these circumstances the haemorrhage is usually an intermittent and sub-
ordinate feature. The diagnosis rests on the characters already given.
When small in quantity the blood often passes backwards into the throat
and is swallowed, or it may be expectorated or coughed up, and be mis*
taken for hsematemesis or haemoptysis.

(b) With CoNSTrruTiONAL Causes the bleeding is usually, although
not always, of larger quantity, and it may, indeed, be so profuse as to
endanger life. The blood in this group comes from a spot near the anterior
part of the septum. Among the predisposing causes none is more frequent
than an idiopathic tendency which exists in certain individuals to bleed
upon slight provocation, a tendency which runs in families. Without
amounting to haemophilia, certain persons undoubtedly present some
inherent quality which renders them more liable to bleed from their
mucous surfaces, with or without a wound. It may exist in only one
member of a family, but more often in several brothers and sisters. I
have often noticed that such a predisposition may exhibit the pheno-
menon of atavism and skip a generation. Epistaxis is more frequent in
children, especially in boys. It is also met with in the aged, but only
when vascular disease and some of the other conditions about to be men-
tioned exist. The constitutional cases may be grouped under (a) Altera-
tions in the Cardio-vasoular System, and (b) Altered Blood States.

(a) Epistaxis occurring for the first time in an apparently healthy
person over forty years of age should always give rise to the suspicion of
chronic Bright's disease. It affords us, moreover, an indication for the
treatment of this malady, of which advantage may sometimes be taken,
for it relieves the vascular tension which would otherwise seek relief in
some less favourable situation. For instance, I have observed several
patients who, after repeated admissions to hospital for epistaxis, have
finally come in to die of cerebral hsemorrhage. Epistaxis is a frequent con-
sequence of cardiac valvular disease, emphysema, chronic bronchitis, and,
cirrhosis of the liver. It may also be an evidence of lardaceous or other
disease of the vessels. Finally, epistaxis is one of the forms of vicarious
menstruation, and, like the bleeding which may take place in hysteria and
other conditions where the vaso-motor system is disordered, we must regard
this as an extreme effect of disease of the sympathetic nervous system.

(b) Concerning Altered Blood States, it may occur with purpura, haemo-
philia, scurvy, leukaemia, anaemia (simple, and especially pernicious), and
the specific fevers, especially typhoid, rheumatism, and the haemorrhagic
forms of the exanthemata. It is in children a not infrequent prodromal
manifestation of whooping-cough and similar microbic disorders.

Prognosis, — Slight epista2ds in children is of no consequence, but occur-
ring for the first time in persons at or past middle life should receive our

§ 184 ] EPISTAXIS 209

serious attention, and its cause should be carefully investigated. Inquiry
should always be made as to whether it has occurred previously in the
life of the individual, because, as above mentioned, certain persons have
this tendency, and in these the symptom may not be of much importance.

Treatment, — The indications are — first, to check the haemorrhage if
profuse ; and secondly, to ascertain the cause.

The epistaxis which accompanies Bright's disease, and the congestion
of cardiac and pulmonary disease should not be checked unless the amount
be profuse. In such cases the epistaxis is usually preceded by headache,
and is accompanied by high arterial tension. It may be one of Nature's
methods for the relief of congestion, as evidenced by the fact that the
headache and the high arterial tension are relieved by the haemorrhage.
In all cases of epistaxis, the first thing to do is to examine the arterial
tension. So long as this remains high or moderate no harm can accrue
from the epistaxis.

(a) The treatment of the attack resolves itself into checking the hsemor-
rhage. The patient should be kept perfectly quiet, with the head erect,
and chin forward, the head being cool, the feet warm, with hot bottles if
necessary. The arms may be raised above the head and ice applied to the
lower cervical spine. A homely substitute for the latter has long been
in vogue in the form of the front-door key. Some recommend pressure
to the anterior part of the septum by the thumb and forefinger externally.
The cautery applied to the bleeding spot is also efficacious. Other useful
measures consist of the application of hydrogen peroxide or adrenalin to
the site of the haemorrhage, if this can be discovered, or the use of styptic
sprays or hamamelis, catechu, vinegar, lemon-juice, etc. Finally, if all
these fail, the posterior nares must be plugged. If haemorrhage continues
for several days, internal treatment must be given — calcium chloride and
terebene. Serum, especially horse serum, may be injected subcutane-
ously.

(6) Between the attacks a very thorough investigation of the nasal and
post-nasal cavities must be made. Minute lesions, quite sufficient to cause
epistaxis, are very easily overlooked. The treatment of recurrent epistaxis
is not always an easy matter, for the cause is often obscure, and we are
often driven to regard the case as belonging to the idiopathic group above
referred to. In a good many cases iron is efficacious in warding ofi the
attacks ; and calcium chloride by increasing the coagulability of the blood.

THE THYKOID GLAND.

This gland is anatomically connected with the upper respiratory pas-
sages, but is physiologically quite separate. It supplies an essence to the
economy which is necessary to the well-being of the individual, and it is
in close relationship with the other ductless glands, the supra-renal, the

pituitary, the pancreas, the ovary and others. In health it enlarges at

210 THE THYROID QLAND [§186

puberty, during menstruation, sexual excitement, pregnancy, lactation,
and in the presence of most acute specific fevers, notably rheumatic fever.
Symptomatology. — There are two opposit<3 clinical conditions which
may arise from disorder of the thyroid gland. In one there is a diminished
thyroid action, a condition of Athyroidiamy the symptoms of which (leth-
argy, lowered vitality, and impaired growth and development) are similar
in kind but less in degree to those of Myxoedema and Cretinism. The
other condition is one of increased (or perverted) thyroid action or Thyroid-
ism, the symptoms of which resemble Graves' disease ; and these, with
the exception of the proptosis, can be produced by the internal administra-
tion of thyroid gland or extract in large doses. It is important to remem-
ber that the size of the gland is not in any degree a guide to which of these
two sets of symptoms are to be expected in a given case, for enlargement
of the gland is consistent with atrophy of the glandular elements and
diminution of function ; while what appears to be a small gland may be
functionally very active.

§ 135. Physical Examination and Classification. — ^There are but two
physical signs referable to the thyroid gland — viz., enlargement or diminu-
tion of volume. When the alteration of volume is only slight it is difficult,
if not impossible, to estimate it with accuracy, because it is partially
covered by muscles, and is intimately connected with the trachea and
other deeper structures. The patient should be instructed to let his head
fall forwards and to swallow whilst we endeavour to palpate the gland.
The thyroid rises during deglutition as no other neck tumour or organ
does. Some idea may be obtained of the progress of a case by measuring
the neck from time to time, always exactly at the same level.

Classiflcation. — In general, enlargement is attended by a condition of
thyroidism {e.g.. Graves' disease), and a diminution by a condition of
athyroidism (e.^., myxoedema) ; and there are two well-marked types of
disease which are usually associated with enlargement, and two with
diminution in volume of the thyroid gland.

(a) The two diseases (besides cancer and other neoplasms) in which
enlargement of the thyroid is — at some stage of the malady — the essential
or pathognomonic feature^ are —

I. Graves' Disease — or Exophthalmic Goitre — is the term applied to
that form of enlargement of the thyroid which is attended by proptosis,
and by numerous cardio-vascular and nervous symptoms, with marked
disturbance of the general health. These general sjmptoms collectively
constitute thyroidism. They are often present long before there is any
visible enlargement of the gland.

II. Simple Goitre or ** Bronchocele " is the term applied to a simple
increase in size of the thyroid gland, either congenital or coming on in

^ In Acromegaly (Chapter XVII.) the thyroid is sometimes slightly enlarged or
diminished in size, but it has generally been regarded as a subordinate Mature in this
rare and strange disease. In some cases of Cretinism (which is included in group h)
the thyroid gland is considerably enlarged, but deficient thyroid action constitutes the
chief factor of the disease.

186 ] OR A VE8* DISEASE 21 1

childhood or early adult life, generally attended by slight though definite
diminution of function.

(6) There are also two diseases in which atrophy of the thyroid — or at
any rate a diminution of its function (and usually of its size) — is the essen-
tial feature of the malady :

I. Cretinism is the term applied to the condition of stunted growth
(both in mind and body) of the individual, due to congenital atrophy or
absence of the gland function, although the gland itself may be either
enlarged or diminished in size. It is a condition of congenital athy-
ROiDiSM. The disease is endemic in certain districts.

II. Mtxcedema is the term applied to the group of symptoms (lethargy,
low vitality, etc.) which, coining on in adult life, especially towards middle
age, accompany atrophy of the thyroid gland. This is a condition of
acquired athyroidism.

It therefore follows that :

1. Increased or disordered thyroid secretion gives rise to profound disturbance of
the general health, and neuro- vascular irritation (Graves' disease).

2. An innocent enlargement of the thyroid, unaccompanied by increased or dis-
ordered thyroid secretion, has no effect on the economy (as in most cases of broncho*
oele).

3. Simple absence or diminution of the thyroid secretion results (a) when it is
congenital or comes on in early life, in deficient development, mental and physical
{i.e,, cretinism) ; and (6) when it supervenes in adult life, in lethargy and deficient
vitality (myxcedema).

Diseases usuaUy attended by thyroid enlargement — viz,, Graves'
Disease and Bronchocele.

§ 136. Graves' Disease (Synon. : Exophthalmic Goitre, Basedow's dis-
ease) has been defined on the preceding page. Usually the onset is very
insidious. There are five groups of sjmptoms, and the varieties of the
disease depend on which of these predominate.

Symptoms. — (1) Cardio-vasctdar disturbances are among the earliest and
most important symptoms. They are never absent, and may exist for
months before any other evidence appears : (i.) Palpitation, (ii.) The
increased frequency and tumultuous action of the heart is accompanied
by a rapid and sometimes feeble pidse, up to 150 or more on the slightest
exertion or emotion. The rate may sometimes be reduced by absolute
rest by 40 or 50. (iii.) Paroxysmal dyspnoea and a distressing sense of
suffocation, produced and relieved by the same means as the preceding,
(iv.) Evidences of cardiac disease, such as the murmur of dilatation (said
to be present in two-thirds of the cases, § 44), are frequently present. The
commonest murmur is a systolic, heard loudest over the second left
costal cartilage, and sometimes propagated up the vessels of the neck,
(v.) Sometimes slight dropsy and occasionally albuminuria are observed.

(2) Nervous disturbances are always present. They are very variable :
thus (i.) there may be nervousness, irritability, insomnia, depression
alternating with excitement, hysterical attacks, melancholy, or mania,
(ii.) Hyperaesthesia, perverted sensations, neuralgic headache, vertigo,
tinnitus aurium, and hallucinations of sight or hearing, (iii.) Other fairly

212 THE THYROID OLAND [§1S6

common symptoms are fine and rapid vibratile tremors of the hands
(always), or of the lips (seldom), (iv.) Vaso-motor disturbances of many
different kinds, intolerance of heat, sudden perspirations and cutaneous
disturbances such as pigmentation and loss of hair. Diarrhoea is a very
common symptom.

(3) Thyroid Enlargement is always present at some stage of the disease,
though it is rarely the first symptom noticed by the patient, probably
because there are no means of detecting slight enlargements. Therefore
in the early stages we have to rely upon the other symptoms. The en-
largement varies considerably in different cases, and is by no means
proportionate to the other symptoms, because the symptoms depend
more upon the histological element of the gland which is involved than
the degree of enlargement (p. 210). Mechanical effects of thyroid enlarge-
ment may be present (see Bronchocele), and occasionally alteration in
the voice from this cause is the first symptom noticed by the patient.

(4) Exophthalmos (proptosis or protrusion of the eyeballs) is present in

a varying degree, though sometimes not imtil late in the disease (Fig. 2,

§ 10). It is best detected by seating the patient in a chair, standing

behind him, and looking down his forehead. As a rule no changes can

be detected in the fundi. Later on ulceration of the cornea occasionally

takes place, either from neuro-trophic causes or from deficient protection.

Four signs of Graves* disease referable to the eyes bear the names of different
physicians. Von Oraefe's sign is a condition in which the upper ejrolid does not
follow the eyeball when this makes a downward movement. Moebiua^s sign is an
insufficiency of convergence of the two eyes when looking at a near point. Stellwag^s
sign is an absence or deficiency of blinking as an involuntary act. Abadie^s sign in
tlSs disorder is an involuntary twitching or spasm of the levator palpebrsB superioris.
All except the first are present only in advanced cases, and are not therefore of very
great value in the diagnosis.

(5) The general health of the patient is always disturbed. Anaemia is
pronounced, and is usually in proportion to the severity of the other
symptoms. Progressive weakness is always present. The varieties of the
disease depend on which of these five groups of symptoms predominates.

Etiology. — (i.) Upwards of 95 per cent, of cases are females, (ii.) A
large number are young adults between the ages of fifteen and thirty,
(iii.) Locality has no known influence, (iv.) Heredity has not been traced
so far as the disease is concerned, but the family often show neuroses in
the shape of epilepsy, chorea, hysteria, insanity, etc. (v.) Fright, anxiety,
love affairs, and mental overwork are potent factors in determining the
disease.

Diagnosis. — The five cardinal symptoms are : (i.) thyroid enlargement,
(ii.) proptosis, (iii.) rapid cardiac action, (iv.) fine tremors of the hands,
and (v.) mental and emotional instability.

Prognosis. — The duration of the disease varies from some six months to
many years. It may certainly shorten life, but many very severe cases
have recovered under modem methods of treatment. The mortality has
been variously stated as from 10 to 50 per cent. ; probably more modern

§187] GRAVES' DISEASE—BRONGHOCELE 213

statistics would give only from 5 to 10 per cent. If the duration be pro-
longed, the disease will certainly leave its mark upon the cardio-vascular
system. The prognosis is always anxious in the direction of mental
instability. Those who recover not infrequently develop myxoedema.

Treatment, — The early recognition of the disease is very important, for
a great deal can be done in the early stages. Rest in bed is the prime
essential. Freedom from fuss and worry is very important. The patients
are always difficile, but those about them should avoid thwarting or
arguing with them. Of drugs, belladonna is the most successful. Bro-
mide of quinine often succeeds admirably. Digitalis and heart tonics
should be avoided ; iron and arsenic are useful ; iodides are contra-
indicated. The most successful therapy is by means of extracts of some
of the other internal secretory glands. Thymus gland has been used with
success ; so have supra-renal, pituitary, and ovarian extracts. Leonard
Williams has had excellent results with the intramuscular injection of
bile salts {Practitioner, November, 1911). Extirpation of the thyroid or
division of the isthmus has been successfully adopted as a remedial measure,
and is indicated when the gland is greatly enlarged, causing dyspncea, or
when medical treatment has failed after a fair trial. Excision of part of the
diseased gland, under local anaesthesia, preceded in some cases by ligation
of the thvroid bloodvessels, has also been successful in a number of cases.
(Dunhill and Kocher, the Lancet, Feb. 17 and March 2, 1912.)

Galvanism (doscendlng) is often useful, and small doses of X lays have given good
results in some cases. Parathyroid gland has been administered, but without con-
vincing results. The discovery that the thjnroid is a protective gland, which neutralises
circulating toxins, has led to the trial of various sera. Thus Moebius has injected a
serum prepared from the blood of thyroidectomised sheep, and Murray a serum from
rabbits, fed on increasing doses of thyroid extract. Rodctgen, the desiccated milk of
dethyroidised goats, has given good results, but all these recent methods require much
longer trial to estimate their value.

§ 187. Bronohocele (Simple Croitre) is another form of enlargement of the thyroid
gland. It may affect the whole organ, or only one of its lobes, or the isthmus. Ana-
tomicaUy, the enlargement may be due chiefly to parenchymatous increase or to cystic
enlargement. The enlargement may be so great that the organ amounts almost to
the size of an infant's head.

The Symptoms which attend the disease are those due to the mechanical pressure of
the tumour, and it is by the absence of the cardio-vascular, nervous, and other
symptoms that this condition is distinguished from Graves' disease. The chief
pressure symptoms are referable to the larynx and trachea. The voice is modified
early in the disease, and vertigo, due to pressure on the vessels, may be present. The
general health may be good, but the patient is usually somewhat anaemic, otherwise
the symptoms are those of athyroidism rather than of thyroidism. It may be Diag-
nosed from other tumours in the neck by the fact that it invariably rises with the
larynx during deglutition. The enlargement generally increases steadily, but it is
only rarely that there is any danger from tracheal obstruction and asphyxia.

The Etiology of the condition is not well known. More often females arc affected,
and it sometimes starts during pregnancy, or a catamcnial period, but it is most prone
to start during adolescence. The disease is endemic in certain districts, and these
for the most part are valleys which have a calcium or a magnesium and limestone
subsoil, together with a large amount of sulphate and carbonate of lime in the drinking
water. That it is not entirely due to the last-named condition is shown by the fact
that in districts where this permanent hardness of water exists bronchocele does not

214 THEjrUYROlD QLAND [ § 188

occur. Captain McCarrison^ believes that the endemic goitre of Chitral and
Gilgit is due to amoeboid organisms. Dogs, horses, and mules suffer also from the
condition.

Treatment. — ^The patient should, of course, leave the district ; or, if this is impossible,
the water used for drinking purposes should be boiled. In McCarrison's cases cures were
obtained by vaccines prepared from the stools, and by intestinal antiseptics, especially
thymol and lactic acid bacilli. In this country it is found that small doses of thyroid
extract (gr. J to J), together with the local application of Ung. Pot. lod. to the tumour,
will generally effect a cure. Arsenic is also useful. Surgical interference may be
necessary.

Disease in which the thyroid is usually diminished in size — mz,,
I. Cretinism, II. Myxcedema. The latter is described elsewhere, since the
leading symptom is General Debility {Chapter XV L).

§ 188. Cretinism is a condition of dwarfism and deformity attended by mental
imbecility, due to an absence or perversion of the thyroid secretion, and is endemic
in certain districts. In advanced and typical cases the face is characteristically
broad and flat, the tongue protrudes from the mouth, the eyes are wide apart, and
the head is brachycophalic {i.e., broad transversely). The skin and hair are dry and
coarse, and the mental condition is extremely backward. In severe cases the body
may be so dwarfed that a person of twenty is the size of a child of five. The limbs
are shortened, the neck stunted ; pads of fat are present above the clavicles ; the hands
are short and square (spade-like), the abdomen prominent, and an umbilical hernia
is often present. The thyroid may be enlarged, small, or absent (see Figs. 6 and 7,
J 19). Kushton Parker* distinugishes three varieties, both etiologically and patho-
logically. In one, the thyroid is embryologically not developed, or only partially
developed, the cause being presumably akin to that which brings about other embryo-
logical deficiencies, such as acardia, acephalia, etc. In a second, the thyroid under-
goes the same changes as in endemic goitre, and doubtless from the same cause, any
differences being due to loss of thyroid function. In a third, the thyroid, after per-
forming its functions healthily for a time, atrophies, doubtless from causes akin to
those of adult myxcedema.

Etiology. — Cretinism is endemic in certain districts — e.g., the valleys of Switzerland.
Cases occur also in certain parts of England, especially in the valleys of the Lake
District and Derbyshire. Sporadic cases are found in healthy families. The causes
are unknown. Some attribute it to consanguinity of the parents, to alcoholism,
tubercle, sjrphilis, or to maternal worry during pregnancy. It is associated with
deficient thyroidal function, and hence may be regarded as congenital myxcedema. In
slight cases of cretinism the diagnosis from other forms of mental deficiency may be
difficult. The condition of the skin and hair are valuable diagnostic features.

Prognosis. — ^The patient may grow up capable of doing light manual work, or may
remain an idiot. Under treatment begun early, the child may recover completely,
but in other cases, although the body is greatly improved, the mind does not improve
in proportion.

Treatment. — ^Thyroid extract, beginning with ^-grain doses (6 grains of raw gland),
causes a rapid and remarkable change. The skin becomes soft, the general conforma-
tion normal, and, if the treatment has not been too long delayed, the mind assumes
its natural vigour. The patient must continue to take the thyroid all his lifo, or else
he will relapse. A case showing the remarkable efficacy of this treatment is figured
in §19.

Complete myxcBdema is dessribed in detail elsewhere (§419). It should
be remembered that there are degrees of thyroid insufficiency which,
though falling short of typical cretinism or fully developed myxcedema,
are nevertheless sufficient to account for many of the minor troubles for

^ Proceedings Royal Society of Medicine, December, 1908, and January, 1912; and
see the Lancet, 1911, p. 1346, vol. ii. and vol. i., 1912.
^ ** Acquired Cretinism, or Juvenile Myxcedema," Brit. Med. Journ., May 29, 1897.

§ 188 ] CRETINISM 215

which patients seek advice. In childhood such deficiency shoidd be sus-
pected if adenoids or nocturnal enuresis are present. In adults, especially
in women about the menopause, increase of weight, falling hair, intolerance
of cold, muscidar fatigue, a slow pulse, a dry skin with a tendency to
chronic eruptions, are all suspicious features. In younger women prema-
ture greyness, and in men premature baldness, are also suggestive. Rare-
faction amounting to complete absence of the outer two-thirds of the eye-
brow is a fairly constant sign. The treatment is by thyroid extract in
very small doses (i^ to J grain three times daily). Large doses often
aggravate the condition.^

^ Dr. Leonard Williams, "Adenoids, Nocturnal Enuresis, and the Thyroid Gland
(Bale and Sons); also "Thyroid Insufficiency," Clinical Journal, 1909.

CHAPTER VIII

THE MOUTH, TONGUE, AND GULLET

The Month.

(Lips, Breath, Saliva, Teeth, and Gums.)

We often regret that we cannot investigate the internal organs more
thoroughly, but how seldom do we avail ourselves of the instructive
information afforded by a thorough examination of the mouth ? Many
of the indications of syphilis, hereditary or acquired, may be so revealed ;
several other constitutional conditions produce symptoms in this locality,
such as anaemia and lead-poisoning ; and a good idea of the general con-
dition of the patient can be obtained from a careful inspection of the
tongue. Many of the disorders special to the mouth are comprised among
the "causes" of stomatitis. For the diagnosis of these disorders it is
necessary to make a thorough examination of the Lips, the Breath, the
Saliva, the Teeth, and the Gums. We will consider the symptoms
referable to these structures in that order.

§ 139. The Lips. — Dryness of the lips is often one of the most conspicuous
evidences of indigestion, and it is a very useful one, because this disorder
has so few physical signs to assist us. The lips are pale in anaemia, they
are cyanosed in advanced bronchitis with dilated right heart, and in many
other conditions (see Cyanosis, § 26). This cyanosis is especially marked
in congenital heart disease. The hard chancre of syphilis may occur on
the lip, § 404. In elderly men epithelioma may occur on the lip. Fissures
around the lips are an almost infallible sign of S3rphilis, especially when
surrounded by a reddened infiltration. This infiltration helps us to dis-
tinguish a syphilitic fissure from the " cracked lip " which is the only
condition liable to be mistaken for syphilis. Cracked Up occurs mostly
in nervous children who lick and bite their lips and are exposed to cold
winds. It can generally be remedied by the application of some simple
ointment, such as zinc ointment or cold cream, whereas the syphilitic
fissures do not yield to this treatment. By pressing the comer of the
mouth inwards and forwards when the patient opens it, we may often
detect a mucous patch surrounding a syphilitic fissure inside the mouth.
The scars left by syphilitic fissures are also a useful indication of a previous
attack, or still more frequently of the patient having had congenital

216

S§ 140-142 ] THS BREATH—THE SALIVA— THE PALATE 217

manifestations. They are white and stellate. (See § 11 for other
conditions.)

§ 140. llie Breath should be normally quite free from any kind of
odour. Offensiveness of the breath may arise from four sources : (1) A
want of cleanliness in the mouth, particles of decomposing food, and the
presence of decayed teeth, may give rise to a very offensive odour of the
breath. (2) Dyspepsia, constipation, and other conditions of the alimentary
canal, and the derangement of digestion in fevers, may also produce a bad
smell of the breath. (3) Some diseases of the nose ; thus it always accom-
panies ozsena. (4) A large cavity in the lungs, especially if bronchiectatic,
and gangrene of the lungs produce a putrid odour (§§ 103 to 105). The
odour of bronchiectasis is characterised by being intermittent ; it comes on
suddenly, lasts a day or two, and disappears gradually. Certain general
conditions are attended by a more or less characteristic odour of the breath.
Thus, in diabetes it is sweet ; in acute alcoholism it is alcoholic or ethereal.
In urcemia it is said to be urinous. Certain drugs give rise to a very charac-
teristic odour in the breath — e,g., turpentine (a resinous odour), chloral
(odour of chloroform), bismuth (odour of garlic), and opium (odour of the
drug). Alcohol, ether, chloroform, and many other volatile substances
are partly excreted by the breath.

§ 141. The Saliva may be increased (i.) in mouth inflammations ; (ii.) in
chronic gastritis, in which there is such a profuse flow of saliva during the
night that it gives rise to the impression that the patient, in the morning,
is vomiting clear alkaline fluid (water- brash or pyrosis) ; (iii.) in pregnancy,
and in mania, hydrophobia, and some other diseases ; (iv.) after the adminis-
tration of mercury, pilocarpine, bitters, and, according to some, alkalies and
acids. The saliva may appear to be increased in cases of bulbar paralysis
or mental deficiency. The saliva is decreased (i.) in certain febrile states,
(ii.) in diabetes, (iii.) severe diarrhoea, (iv.) chronic Bright's disease, and
(v.) during the administration of atropine or daturin. A condition known
as " dry mouth " (xerostomia) has been described by same authors,^ in
which there is a constant deficiency of saliva. The cause of this is obscure.

§ 142. The Palate may be " cleft " from childhood, otherwise a hole in
this situation is practically always an evidence of past syphilis. The soft
palate shares in the diseases of the fauces (§ 108). It is a favourite position
for the membrane of diphtheria, which in this situation forms an important
means of differentiating the disease from follicular tonsillitis, the exuda-
tion of which never affects the palate. The hard palate is sometimes in-
volved in the diseases of the floor of the nose. A swelling may appear
here in abscess of the antrum, or in abscess dependent on disease of the
lateral incisor tooth. The latter is the commonest cause of swelling in
this situation, according to Tomes (loc, cit.).

Thirst accompanies all febrile conditions and inflammatory conditions
of the gastric mucous membrane. It is met with also in diabetes, after
diarrhoea and vomiting, and after a diet excessively salted.

1 Clin. Soc. Trans., 1885.

218 THE MOUTH, TONGUE, AND GULLET [ §§ 148, 148a

§ 143. The Teeth are subject to a certain amount of variation, even in
health. The average dates of the eruption of the temporary and permanent
teeth are as follows :

Temporary or " Milk " Teeth. Permanent Teeth.

About 6th to 8th month, lower central About 6th year, first molars,
incisors.

About 8th to 10th month, upper in-
cisors.

About 12th to 14th month, first molars.

About 18th to 20th month, canines.

About 2 to 2^ years, posterior molars.

7th ,, central incisors.

8th ,, lateral incisors.

9th „ anterior bicuspid.
10th ,, posterior bicuspid.
11th to 12th year, canines.
12th to 13th „ second molars.
17th to 26th „ third molars.

One quarter of the mouth may be represented diagrammatically thus :
Teeth .. I. I. C. M. M. | Teeth .. I. I. C. B. B. M. M. M.

Month of 1 o n lo ^rt «^ I Year of

... 6 9 18 12 24 ' -^"-JoU 7 8 11 9 10 6 12 24

eruption. J ^ eruption.)

The normal order of eruption of teeth may be represented thus : Milk
teeth, C, 9, 18, 12, 24 months ; and Perbianent teeth 7, 8, (11), 9, 10 ;
G, 12, 24 YEARS. These details are worth remembering, because defective
or deficient teeth are nowadays an extremely frequent cause of faulty
digestion.

The presence of decayed teeth is one of the commonest causes, if not
the commonest, of the dyspepsia of modem times, and it is an ominous
feature that a very large proportion of the candidates for the Army and
Navy Services are rejected because of bad teeth. They decay early in
rickets, in cretinism, and in some other constitutional conditions.

The teeth are altered in shape after stomatitis in early life, which may
be due to mercury, etc. {vide § 146). In these circumstances the teeth
present transverse and vertical ridges, with or without alteration of shape.
" Hutchinson's teeth " show alterations in the shape of the permanent
teeth, due to hereditary syphilis, and present a valuable means for the
identification of this disorder, as they are of very frequent occurrence in
that disease, and bear lifelong testimony. They are set apart and are
both pegged and notched — that is to say, the transverse measurement is
smaller at the free edge than the part near the gimi, and on the edge of
each tooth there are one or two notches (see Fig. 3, § 11).

§ 143a. Toothache (odontalgia) is caused most frequently by decay
(caries) of the teeth ; but there are other causes, the chief of which, as
given by Mr. C. S. Tomes, are as follows :

1. Morbid conditions of the tooth-pulp, including irritation, acute and chronic
inflammation of the pulp, pressure from confined matter in the pulp cavity, and
deposit of secondary dentine in its substance. 2. Exposure of sensitive dentine,
with or without caries, is probably the commonest cause of toothache — a " hollow
tooth,'' as it is called. 3. Morbid conditions of the alveolar periosteum, odontoma,
and exostosis, including inflammation of the periosteum, acute and chronic alveolar
abscess, lesions manifested by alterations of the roots of the tooth. 4. Morbid con-
ditions of the periosteum of the jaw — e.g., traumatic, rheumatic, strumous, or syphilitic
periostitis. 5. Irritation of the dental nerves by causes not productive of visible local
lesions. This may include malposition and retarded eruption of wisdom teeth, and

144,146] THE QUM8—PY0RRH(EA ALVE0LARI8 219

pressure due to insufficient space for the teeth. 6. Inflammations and ulcerations of
the miLcous membrane and submucous tissue.

This is merely an approximate clekssification. The character and degree of the pain
is greatly modified by the condition of the patient. The pain is genorally more or less
intermittent. It is oftan absent at periods of full vigour — e.g., after breakfast or
dinner. Pain due to irritation, or to chronic local inflammsbtion of the pulp, partakes
of a neuralgic character, and the patient is often unable to point out the affected tooth
or teeth. The suffering induced by acute inflammation of the pulp is excessive,
particularly if there be no exit. It ceases more or less abruptly from the consequent
death of the pulp. The recumbent posture or active exercises serve to aggravate the
pain by increasing the vascular supply.

The Treatment belongs to the dental surgeon, but a good deal of temporary relief
may sometimes be obtained by constantly rinsing the mouth with hot carbolic lotion
(1 in 100). A formula for drops to apply to a hollow tooth is given in Formula 23 at
the end of this book.

Although the term Eptdis should be restricted to new growths of a malignant
character springing from the alveolar portion of the jaws, it is often employed to
indicate any proliferation of tissue in that situation. The commonest form is that of
a papillomatous proliferation of granulation tissue at the base of a carious tooth.
This should be removed with a small portion of the periosteum. True epulis starts
in much the same way, but is in reality a fibro-sircoma growing from the periosteum.
It spreads along the gum, and should be excised early. A myeloid growth from the
cancellous tissue of the jaw may simulate epulis ; so may an epithelioma. The true
epulis is a periosteal growth.

§ 144. The Gums. — ^The pallor of ansBmia, the purple line of lead-
poisoning, the red and ulcerated condition in stomatitis, the sponginess
in mercurialism and scurvy are all useful local indications of some general
condition. A swelling of the gums with greenish discharge suggests
Actinomycosis. Bleeding from the gums is apt to occur in scurvy, purpura,
the hsemorrhagic diathesis, and even in apparent health, when the teeth
are covered with tartar and the gums recede. In some people the gums
very readily bleed, and suck'mg them may produce bleeding, which enables
malingerers and hysterical persons to simulate diseases of the lungs or
stomach. It is detected by being only in small or moderate quantity,
and by its intimate mixture with saliva. There is one disease of the gums
— Pyorrhoea Alveolaris — the importance of which has only recently been
recognised.

§ 145. Pyorrhoea Alveolaris (Riggs* disease or Suppurative Gingivitis)
is a raw ulcerating condition of the gums around the sockets of the teeth
or stumps. When tartar is allowed to collect upon the teeth, it gradually
pushes the gum back ; and by degrees a pocket or fossa is formed around
the neck of each tooth, and there is considerable sero-purulent and often
blood-stained discharge from the pockets thus formed, which not only
imparts an offensive odour to the breath, but, being continually swallowed,
is absorbed, and sets up a chronic toxsemic condition, which it is now
recognised may produce a large number of troublesome symptoms.^ Dys-
pepsia, even apart from difficulties of mastication, invariably ensues
sooner or later. But even before the dyspepsia becomes established the
patient is listless, languid, and unfit for work, and complains of a great

* This subject was the topic of an interesting discussion at Roy. Med. Chir. Soc,
June, 1900. The blood-stained discharge is liable to be mistaken for serious disease
of the stomach or lungs, as in cases mentioned at that discussion.

220 THE MOUTH, TONGUE, AND GULLET [ j 146

variety of functional nerve symptoms. A large proportion of my out-
patients at the Nerve Hospital who complain of functional neuroses owe
their troubes to pyorrhoea alveolaris. Among the symptoms due to this
cause I may mention headache, neuralgia, pains or tingling in the limbs
and prostration, attacks of flushing, or giddiness ; a feeling of heaviness,
and swelling of the limbs which is sometimes attended by cedema of the
ankles, wrists, and other parts, which differs from ordinary anasarca in
requiring longer pressure to produce the pit. Great depression is usual,
and even melancholia may result; one of my patients committed
suicide. Rheumatoid arthritis and fatal ansBmia may also occur.

Treatment. — All these symptoms may arise when, for instance, stumps
are left beneath an artificial plate. If the pyorrhoea, as frequently hap-
pens, be not identified as the cause and removed, no treatment is of much
use. The tartar must be removed at intervals of a week or so by a skilled
person, and the suppurating pockets must be carefully dressed daily by
the patient, with sulphate of copper, iodine, or peroxide of hydrogen.
The only radical cure is the removal of the stumps or teeth if these
are at fault. Recently vaccines prepared from organisms cultured from
the gums have been employed in conjunction with local treatment.

§ 146. Stomatitii is a generalised inflammation of the mouth, evidenced by redness,
swelling, tenderness, and pain of the mucous membrane, swelling and protrusion of
the lips in severe cases, offensive odour of the breath, and usually, but not always,
excess of saliva. This, the simplest form of stomatitis, such as occurs in dentition
or the application of caustics, is known as (a) Catarrhal or Erythematous Stomatitis,
{b) Aphthous Stomatitis, also known as Vesicular or Herpetic Stomatitis, occurs in badly-
fed children, and it presents, in addition to the above features, small grey patches,
with a red base and sharply-defined circular margin, resembling vesicles, which may
be very painful to the touch, (c) Ulcerative Stomatitis occurs in a mild, and also in a
severe form. In this we find, in addition to the features belonging to variety (a),
irregular ulcers, especially on the gums which recede from the teeth, so that the teeth
become loosened. In the severe form there is great f oetor of the breath, considerable
enlargement of the glands, submaxillary and cervical, and constitutional disturbance ;
and the teeth may drop out of the ulcerating gums. The ulcers often have a yellowish
or grey coating, resembling a membrane, and it is therefore sometimes called *' pseudo-
membranous stomatitis,'* or ** phagedenic gingivitis." {d) Gangrenous Stomatitis
(Cancrum Oris, Phagedena Oris, Noma Oris) is a gangrenous inflammation starting
at one spot, usually on the cheek or on the lips. At first there is acute pain,
but as this passes off a black spot forms (usually both internally and externally),
which spreads and leads to perforation of the cheek. The inflammation may spread
to the gums, and the teeth become loosened. This is a severe disease, attended by
considerable prostration, and, at first, a subnormal temperature. It is apt to follow
measles or other exhausting illnesses in weakly children exposed to bad hygienic con-
ditions.^ (e) Pyorrhcea Alveolaris has been separately described above (§ 146).

^ Micro-organisms probably plav a more important part than is at present recognised
in the pathology of stomatitis, and the entry of these or^nisms into the mouth, where
they may perhaps lodge on some chance abrasion, mi^t possibly account for some
of those hitherto inexplicable cases of the disease. For instance, it seems highly
probable that that extremely serious condition, Cancrum oris, may be connected with
one of the group of bacteria which has lately attracted attention, and which includes
the Bacillus aerogenes capsulatus, B. clematis maligni, B, emphysemaiosis, and other
microbes found in connection with ** acute spreading traumatic gangrene," malignant
oedema, gangrene foudroyante, eto. See, e,g., a paper by Comer and Singer on " Acute
Emphysematous Gangrene/* the Lancet, November 17, 1900 ; and Discussion at the
Patn. 1^., Lond., in the Lancet, 1900, vol. ii, p. 1651.

§ 146 ] STOMATITIS 221

Etiology of Stomatitia. — (1) Certain local conditions, of which the commonest are
dentition, tartar, and a want of cleanliness, the local irritation of a jagged tooth,
excessive smoking, dirty feoding-teats in children, the application of hot fluids and
caustics, new growths (simple or maklignant), and gummata. In most of these oases
the stomatitis takes the form of (a) or (6) above. Mouth-broathing and chronic
gastric catarrh are said also to give rise to stomatitis occasionally, and necrosis of the
jaw may lead to an ulcerative stomatitis. ,

(2) Certain drugs and chemical substances are apt to cause stomatitis. Chief amongst
these is meronry, which gives rise to a very characteristic ulcerative stomatitis, with
"P^^'^Sy gums and great fostor of the breath. Arsenic and iodides may produce
catarrhal stomatitis. Phosphorus produces ulcerative stomatitis, with necrosis of the
jaw. The blue line of lead may be attended by a certain amount of catarrhal stoma-
titis.

(3) Chief among the constitutional conditions which cause stomatitis is (i.) the
lowered vitality met with in phthisis and other wasting disorders, or in badly-fed
children, in whom the stomatitis may bo aphthous or ulcerative. Thrush often
accompanies catarrhal stomatitis in these circumstances, (ii.) Syphilis is aocom
panied by a special variety of the catarrhal form, and is attended by whitish, semi-
transparent patches on the tongpie and mucous membrane, resembling " snail-tracks.**
Later on ulcerations may occur (§ 1 13. Throat). It may also take the form of flattened
white papules, (iii.) Measles and other acnte specific fevers are apt to be followed
by cancrum oris in children expoS'ad to bad hygienic conditions. Diphtheria is at-
tended by both stomatitis and rhinitis when the membrane affects the mouth and nose,
(iv.) Scurvy and purpura are attended by swollen and spongy gums and ulcerative
stomatitis. The acute blood diseases (acute lymphsemia and myelssmia) are accom-
panied by an extreme degree of stomatitis, due to the presdnoe of small pin-head to
sago-grain-sized lymphoid nodules on the gums which readily ulcerate. Not in-
frequently such causes are treated without any suspicion of the true nature of the
disease, although the nodules in question are very characteristic, (v.) Gastro-intes-
tinal derangement, as in dyspepsia and fevers, leads not infrequently to catarrhal
and sometimes aphthous stomatitis, (vi.) A lowered state of health, with insanitary
environment, gives rise to epidemics of ulcerative stomatitis, sometimes taking a fatal
form, in jails, hospitals, and camps. Occasionally this condition is met with in indi-
viduals in private life. (viL) Foot-and-Mouih Disease (Syn. : epidemic stomatitis ;
aphthous fever) is an acute infectious disease attacking pigs, sheep, cattle, and other
domestic animals. Epidemics have bsen reported in which the disease was trans-
mitted to man, with symptoms of fever, gastro-intestinal derangement and vesicles
on the lips, mouth, and pharynx, and sometimes near the nails of fingers and toes.
Death has occurred, but recovery is the rule, (viii.) Sprue and Pellagra show stoma-
titis in their early stages.

(4) Certain skin lesions may invade the mucous membrane of the mouth, such as
the rashes of small-pox, chicken-pox, measles, and herpes iris. In measles certain
spots, first described by Koplik, appear on the inner sides of the cheeks, opposite the
bicuspid or molar teeth, before the skin eruption occurs. They most often take the
form of a greyish-white stippling on a slightly raised purplish base, and afford con-
siderable aid in the early diagnosis of the disease. Lichen ruber planus may affect
the mucous membrane of the mouth and tongue, and it may be present there even
before it appears on the integument. In this situation it hsks a whitish appearance,
much resembling secondary syphilis, for which it has sometimes been mistaken. Lupus
may affect the palate.

Prognosis of Stomatitis, — ^As a rule, stomatitis is not a serious disease, except that
form known as phagedenic stomatitis, in which the mortality is 80 per cent. Catarrhal,
aphthous, and ulcerative stomatitis generally end in recovery in a week or two. Those
cases due to constitutional conditions are, as a rule, far more serious and obstinate
than those due to local or removable conditions. The stomatitis of mercury may
be extremely severe, but is, happily, only rarely seen nowadays. When aphthous
stomatitis occurs in adults, accompanying a lingering disease, it is very obstinate,
and is, in itself, a very grave omen. The prognosis is grave in the epidemic form,
which is probably of miorobic origin. The complications of the phagedenic form are

222 THE MOUTH, TONGUE, AND GULLET [ § 147

diarrhoea, broncho-pneumonia, and gangrene in other parts of the body, especially
the organs of generation (noma pudendi).

Treatment, — In all varieties the indications are (1) to remove the cause, (2) to
alleviate the local inflammation, and (3) to attend to the general health. The teeth
should be scaled and any septic stumps removed. Carious cavities and ulcers on the
gums should be thoroughly swabbed over with 1 in 40 carbolic. It is important to
cleanse the pocke ts at the sides of the teeth which are met with in pyorrhoea alveolaris.
After every meal the mouth should be cleaned of debris with a soft brush, by rinsing
repeatedly with warm water, then with an antiseptic solution. One of the best is
hydrogen peroxide {2\ to 10 vol.) ; others are 1 in 100 carbolic, 1 in 30 boracic. and
sodium bicarbonate 1 in 20. When swelling is pronounced and prevents free access
of these remedies, glycerine of tannic acid may be rubbed on the gums. If the mouth
is very dry, glycerine of borax is useful. A " bad taste in the mouth " may some-
times be overcome by taking tni. of pure carbolic in "^i. water twice daily. Tablets
containing formalin may be sucked at frequent intervals, and are of especial use
when dealing with children.

Aphthous and Ulcerative Stomatitis are best treated by touching the sore places with
solid nitrate of silver or sulphate of copper. For the pain, a solution of cocaine H to
3 per cent.) may be used. In the ulcerative form chlorate of potash is especially useful.
In the Gangrenous form (cancrum oris) prompt measures are necessary to avert a fatal
issue. The affected area should be as freely excised as possible, and any suspicious
tissue left or subsequently appearing may be burnt with the actual cautery. Plastio
operations may be necessary later, but attempts to save tissue at the time are always
fatal. Free use of stimulants and nourishment is called for.

The Tongue.

The alterations to which the tongue is liable will be referred to under six
headings : (a) Furring of its Surface ; (6) Ulceration ; (c) White Patches ;
(d) Acute Swelling ; (e) Chronic Swelling (Hypertrophy), and Atrophy ;
(/) Warts, Fissures, and Cicatrices. A mother sometimes speaks of her
child being " tongue-tied " when the frenum is too short. In some cases
this is really so, or the structure may be attached to the tongue too far
forward, but it exists much less frequently than parents suppose.

§ 147. Purring of the Tongue. — The appearance of the dorsum of the
tongue used to be looked upon by older authors as an indication of the
state of the stomach, and with certain reservations it is still regarded as
some aid in the investigation of that organ {§ 195), though it is a better
guide in the prognosis of fevers and other grave constitutional disorders.
Five varieties of tongue have been described by authors : (1) The fale^
large, flabby tongue, with broad tip and indented edges, and a uniform thin
white coating, is the commonest abnormality. It is met with after alco-
holic excesses, in atonic dyspepsia, in anaemia, and in gouty persons.
(2) A red tongue, with sharp red tip and edges, in which the hypersemic
papillae contrast strongly with the slight white coating in the centre, is
found in subacute gastritis and irritable dyspepsia. (3) The coated tongue,
with a imiform white layer over the surface, is foimd in acute gastritis,
feverish conditions, anaemia, and nervous depression. Two forms of this
tongue have been described : (i.) The strawberry tongue, having a slight
white coating through which the fungiform papillae protrude at the tip
and edges, is very typical of scarlatina and other highly febrile states,
(ii.) The plastered tongue, where the coating is considerably thicker.

§ 148 ] FURRING AND ULCERS OF THE TONGUE 223

The amount of coating on a tongue varies directly with (o) the amount of
dryness of the mouth — that is to say, the deficiency of salivary secretion
(e.g,, in fevers and profuse perspiration) ; and (b) with the immobility of
the tongue, owing to eating food that does not require mastication. The
plastered tongue may pass on to — (4) the furred tongue. The coated
papillae stand out separately, giving a shaggy appearance. It is met with
in states of marked prostration — e.g., coma, abdominal cancer, advanced
phthisis, profound anaemia, and other asthenic states. The prognosis is
grave when the tongue becomes encrusted and its dryness increases.
From any cause it may became dry, brown, and crusted, and then pass on
to — (5) the denuded red tongue, which generally follows the preceding as
the crust falls off. This tongue is red, shiny, smooth, and often cracked.
It is found in advanced states of the preceding conditions, in diabetes,
and other severe chronic ailments. The appearance of this tongue in a
disease is of very grave prognosis. Aphthous stomatitis may supervene.
(6) A pale flabby tongue with marked atrophy of the mucous membrane is
often seen in association with Addisonian (pernicious) anaemia.

Apart from disease, there is no doubt that there are wide individual
peculiarities in the character of the tongue. On this account some^ go so
far as to say that the tongue is of little importance as a cb'nical indication.
Undoubtedly we should make sure in any given case that the tongue
condition before us is not due to these personal peculiarities, to smoking
in excess, or to previous disease.

As regards Treatment, it is an old saying that a red tongue requires

alkalies, and a white tongue acids. The former of these is true to some

extent, but not the latter. With the exception of diabetes, a dry tongue

indicates no appetite, and deficient gastric secretion ; therefore the patient

should be fed on fluids, animal soups, and other things requiring no great

digestive power ; (4) and (5) call for alcohol and other stimulants. In the

prognosis of enteric fever the tongue ia a valuable indication.

That rare condition, black or " Jutiry " tongue, must not be mistaken for a furred
tongue. It is due to elongation of the papillaB at the back of the tongue ; they resemble
dark hairs. The cause is unknown. The condition is best left alone, as it usually
disappears spontaneously.

§ 148. Ulcers of the Tongue may be Simple, Syphilitic, Malignant, or
Tuberculous.

I. Simple Ulcers of the tongue are known by their superficial character,
by the presence of some local cause, such as a jagged tooth or other local
irritation (see also Ulcerative Stomatitis). The frenum is apt to be ulcer-
ated in whooping-cough. This is probably of mechanical origin, but it is
a useful aid in diagnosis.

II. SvpHiLrrio Ulcers are of two kinds : (a) superficial, (b) deep.

(a) Suj>erfictal Syphilitic Ulcers of the tongue are met with usually at
the side, or in the form of fissures on the dorsum (cp. § 113) or superficial
circular " punched-out " ulcers.

* E.g., Sir Jonathan Hutchinson, Med. Press and Cir., July, 1883.

224 THE MOUTH, TONGUE, AND GULLET [ § 149

(6) Deef Syphilitic Ulcers are preceded by the formation of a roundish
nodule (a gumma) which ulcerates. They are recognised by (i.) their site,
which is usually on the centre of the dorsum ; (ii.) their raised, ragged,
and sometimes undermined edges; (iii.) the yellow slough which covers
the base ; and (iv.) the fact that they leave deep stellate scars. Syphilitic
ulcers are usually multiple ; difficulty in diagnosis arises in the case of a
single ulcer as to whether it be syphilitic or cancerous. Syphilitic ulcera-
tion is differentiated by (1) the relative absence of surrounding induration,
and consequently there is less interference with the movements of the
tongue ; (2) the site of ulcer on the dorsum ; (3) there is less glandular en-
largement, and the glands have a shotty feel ; (4) the age of the patient,
malignant ulcers rarely occurring before forty ; and (5) there is a history
of syphilis, and the disease heals under iodide of j>otassium.

III. Malignant Ulcer of the tongue is known by (i.) its site, which
is chiefly on the side of the tongue ; (ii.) its hard, raised, everted edges,
and its uneven warty base, with foul discharge and tendency to haemor-
rhage ; (iii.) the induration around, and the early involvement of the
glands ; and (iv.) the early impairment of the movements of the tongue
with great pain. These are the characters in an advanced case when
diagnosis from syphilis is relatively easy. In an early stage it may be
very difficult. In that stage a cancerous ulcer has flat sloping edges and
scanty secretion, its progress is very slow, and it does not yield to iodides.
Before a suspicious ulcer has existed for any length of time, a small piece
should be excised for microscopic examination.

IV. Tuberculous Ulcers are not common. They are superficial,
with a yellowish discharge, and there is generally a history of tubercle in
the lung or throat. The tubercle bacillus may be found in the scrapings.

Prognosis, — Simple ulcers are easily dealt with, but other ulcers of the
tongue are dangerous chiefly from their liability to haemorrhage and
because of the important structures around. The diagnosis of sjrphilitic
from malignant lesions is as important as it is difficult, for however ad-
vanced the former may be, they yield to appropriate remedies, but the latter
are necessarily fatal unless removed early. The deep ulcers often seen in
advanced Sjrphilitic glossitis are dangerous, as the deeper parts may be
afiected by malignant change.

The Treatment consists of the usual surgical measures. In syphilitic
ulcers iodide should be given in large doses. It is rarely given in sufficient
quantity.

§ 149. White Patches are not infrequently met with on the tongue, and may result
from : I. Thrush ; II. Leucoplakia ; III. Goographioal tongue ; IV. Aphthous Stoma-
titis (§ 146) ; V. Syphilitic Patches (§ 113). The two last are described elsewhere.
The stellate cicatrices so characteristic of syphiltic lesions must not be confused with
any of these.

I. In Thrush (parasitic stomatitis) there are white membranous patches, like
milk curd, sometimes with an areola round them. They are distinguished from other
similar affections by (i.) leaving a bright bleeding surface when they are scraped off,
and (ii.) by the detection of the fungus Oidium albicans {Saccharomycea albicans,
Fie;. 59) on microscopical examination. It usually starts on the tongue, but may

ilM] WHITE PATCHES— GLOSSITIS 226

invade the lips and tlia whole of the interior of tho mouth. The disease occura chieQy
in infancy, also in the later stages of exhausting diwases in adults. In the adult it
only occurs at the end of wasting disorderB, and not JnfrequenUy forms one of the
indications of approaching death. In infanoy it generally arises in hand-fed children
under bad hygienic conditioos. and is often attended by diarrhcBa. It is contagious
from child to child. In children it has no veiy great significance, and readily yields
to glycerine and borai, or weak carbolic lotion (1 in 500). Tho diet and method of
feeding should always receive attention in such cases. In such children it sometimes
happens that excoriations are noticed around the anus, and tho mother thinks the
" thrush has gone through the child " ; but these are more frequently due to congenital
syphilis oreczema intertrigo.

II. Leckoplakia LiitQtr.x (synonym, Ichthyosis Lingun) is a term ap[diod to flat,
whitish, homy-looking, silvery patches on the t«ngue, due to a heaping up and con-
densation of the epithelium. The disease generally involves a conaiderable area of
the tongue. In a later stage the tongue beconcs red and glazed. The patches
themselves are often cracked, and form a pavement- 1 ike surface, which has the
appearance of ichthyosis of the skin. They give rise to a gr^^at deal of discomfort
and tenderness. It is most frequently met with

in tertiaiy syphilis, and. according to most ob-
servera, it is always an evidence of that disorder.
But others attribute the condition to excessive
smoking, jagged teeth, drinking, and dyspepsia. 1
cannot say that I have met with a case which could
not be attributed to syphilis. The TrealmtTit is, as
a rule, very unsatisfactory, unless the disease be met
with in the early stages. A mouth-wash, consisting
of bicarbonate of soda (20 grains to the ounce), or a
ttatiirated soluUon of chlorate of potash, sometimes
relieves the symptoms. But the best treatment, in
my experience, is the local application of chromic
acid [5 to 10 grains to the ounce. gTaduslly increased),
painted on d^y. It should be accompanied by anti-
syphiliUo remedies, though they do not hhve a vety
marked effect. Alcohol, smoking, and other irritants
must be avoided. The tongue should be carefully
watched leat malignant disease supervene. Flj, Eis.— OiflUK albicans.

III. Oeooraphkul or " Mapped "tengue is a con- ob Thkcsh FuNoca.
dition in which the normal desquamation of tho

tongue takes place irregularly, with the fonnation of more or less circular patches
surrounded by margins of slightly proliferating whitish-grey epithelium. The cause
is unknown. It may disappear spontaneously.

SIW. Aont* SwalUng of th« Tonne — i.e., swellingof the tongue coming on rapidly —
may be due to either (ft) AcuU Qlossitia or {b) AcuU (Edema. In both of these the
tongue rapidly enlai^s, and may even protrude beyond the teeth. A great deal of
pain is present, and there is a difficulty of swallowing and spraking.

(a) AoCTE Glossitis may be due to various local cause Et—«. if., the ating of an insect,
a septic wound, biting of the tongue, acute ulcers — or it may be duo to constituljonal
conditions — e.g.. mercurial salivation, and, according to Erame, acute specilic diseases,
such as erysipelas. The onset of acute glossitis ia rapid* though rather less so than
acute (Bdema ; the swelling rarely extends beyond the tongue, and the glands are
sometimes involved. Trtalment consists of the use of mouth-washes, espeoiully
chlorate of potash, painting with a cocaine solution (10 per cent.), the administration
of chlorate of potash, iron, and bark internally, with purging and antiphtogietio
remedies generally. Free incisions may be necessaiy.

(6) AocTB GioBMA OF THB ToKOnE is a serious disorder, because of its liability to
involve the glottis. It may accompany urticaria, angio-neurotJc cedema. or it may
be, like the angina Ludovici (S 116), of an eiysipeloid nature. The cedema comes on
suddenly, and in the oouroe tJ a few hours the tongue may protrude from the mouth.
The swelling rapidly extends to the throat, nose, and down the (esophagus and trachea.

226 THE MOUTH, TONGUE, AND GULLET [ §$ 161-15S

It is attended by an inability to speak, to swallow, and sometimes even to breathe.
Its Causation is obscure, but it is said to be usually of an urticarial nature, and to
occur in those who have had urticarial attacks. This condition is Diagnosed from
simple acute glossitis by (i.) its rapid advent in the course of an hour or two ; (iL) the
rapid extension to the throat and other parts ; (iii.) the presence sometimes of an urti-
carial rash, or a history of attacks of angio-neurotic oedema. Without the last feature
the diagnosis is difficult.

Prognosis and Treatment, — ^The disease comes on rapidly, and runs a very rapid
course, subsiding in the course of twenty-four hours, unless the patient die in the
meantime. It is apt to cause suffocation. Prompt measures are necessary. A strong
purge should be given at once (croton oil, 1 minim, if it can be swallowed) or a turpen-
tine enema. Cocaine (5 or 10 per cent.) should be kept constantly painted on the
tongue. ScariBcation is often required, and the practitioner should be prepared to
perform tracheotomy if necessary.

§ 161. Chronic Swelling, Hypertrophy and Atrophy of the Tongue.

I. Chronic Glossitis is a chronic inflammation of the tongue, in which either the
surface or the substance is mainly involved. The surface is covered with irregular, red,
raw, tender patches and cracks (unless it be secondary to, or attended by, leucoplakia).
If the substance be affected, the organ is enlarged, indented by the teeth, and in course
of time it becomes indurated. It is more frequently due to some local irritation, such
as a jagged tooth or an ulcer, in which case the enlargement is generally limited to
one part of the tongue. Qlossitis may arise from alcoholism, syphilis, chronic dys-
pepsia, or excessive smoking, and many of the other causes of stomatitis (q.v.). The
treatment is directed to the removal of the cause, and the employment of chlorate of
potash and astringent mouth- washes. Tumours of the tongue are rare ; for diagnosis
and treatment of these a surgical work must be consulted. Oveigrowth of the
lymphadenoid tissue at the base of the tongue (the ** lingual tonsil ") is found in local
septic conditions and in the acute blood diseases.

II. Macroglossia is due generally to a congenital overgrowth of the connective tissue,
accompanied by a dilatation of the lymphatics of the tongue. Its causes are obscure.
It is found in mongolism and with acquired syphilitic lesions. Persistent application
of mild caustics or the galvanic cautery to the tongue is the only remedy.

III. Atrophy of the Tongue (microglossia) may arise from nerve lesions. It may
occur in bulbar paralysis, and is then usually bilateral. In unilateral cases the lesion
is either situated in the nucleus or trunk of the twelfth nerve of one side (vide Chap-
ter XIX., § 622).

§ 162. Warts, Fiisores, and Cicatrices.

Warts are simple or S3rphilitic. Simple warts are distinguished by the fact that
they are soft ; they are raised, and often pedunculated, and there is but little secretion.
The glands are not shotty to the touch. Syphilitic warts are hard, with infiltration ;
they are never pedunculated, secretion is present, and the glands of the neck and else-
where are shotty. Fissures are also divided into simple and syphilitic. The simple
can generally be accounted for by some such cause as the irritation of a ragged tooth,
and are n€f7er infiltrated. On pinching syphilitic fissures between the fingers, infiltra-
tion is found to be present. CiCATRiCBS.---Simple ulceration rarely leaves a scar, but
if so, it is never hard. Hard, stellate soars are invariably indicative of syphilis.

« The Gnllei

§ 153. Symptomatology. — ^Diseases of the oesophagus have practically
one symptom which is common to all — namely, dysfhagia — i.e., a difficulty
in swallowing. There are certain features about this symptom which it
is important to investigate :

First, does the difficulty apply to both liquids and solids ? This gives
us an idea of the degree of the obstruction. Secondly, does the food return ?
and if so, after what interval ? This is sometimes a guide to the seat of

§ 164 ] PH Y8IGAL EXAMINATION 227

the obstruction. Obstruction within the oBs&pJiagus has to be distin-
guished from obstruction at the pyloric end of the stomach (i.) by the easy
way in which the food regurgitates as compared with the vomiting which
accompanies pyloric stricture ; and (ii.) by the absence of acidity in the
material returned. Thirdly, is there any pain ? What is its situation,
and is it only present after the ingestion of food ? Constant pain is a
feature of malignant disease. Fourthly, what is the duration of the dys-
phagia ? Has it been persistent, and become progressively and steadily
worse ? The last named is the leading feature of organic, as distinguished
from functional, dysphagia, which is frequently intermittent, and by no
means progressive. Fifthly, is there any regurgitation through the nose ?
This feature implies paralytic dysphagia, with paralysis of the soft palate.
Sixthly, is there any emaciation, or are there any symptoms referable to
other Cleans ? Marked emaciation coming on early in a patient beyond
middle life is characteristic of carcinoma.

§ 154. Physical Examination. — (a) A careful insfedion of the throat
should be made, because the dysphagia may arise from tonsillitis or other
pharyngeal conditions. The paralysb of the palate which succeeds diph-
theria may thus be detected. Any swelling should be carefully examined,
such as retro-phar3mgeal abscess or tumour of a foreign body in this situa-
tion. I have known the bristle of a toothbrush entangled in the pharynx
give rise to very serious difficulty in swallowing.

(h) In cases of dysphagia of any duration the fosaage of ar^ OBsophagecd
hougie, or, at any rate, a soft stomach-tube, should always be made.^
The solid bougie is preferable, both for purposes of diagnosis and of treat-
ment, but if carcinoma be suspected, great care must be exercised. The
chest should always first be examined for aneurysm, and if this cannot
certainly be excluded, the bougie should be avoided. The bougie must
first be dipped in hot water in order to make it more flexible, and glycerine
if necessary for lubrication. There is not much fear of it entering the
larynx, provided the tube be passed to one or other side, and instruction
given to the patient to put his head horizontally forwards and swallow
during the operation. As the entrance to the stomach — ^from the teeth to
the cardiac orifice — is a distance approximately of 16 inches, it is a good
plan to tie a thread round the bougie 16 inches from its point ; then one
can tell when it hets reached the stomach. The oesophagus starts at the
cricoid cartilage, opposite the sixth cervical vertebrse and ends opposite
a point between the ninth and tenth dorsal vertebrs9, a distance of
10 inches. The presence of acute fair^ during the passage of the instru-
ment indicates ulceration, either simple or malignant. The presence of
Uood, and perhaps cancer cells adhering to the end of the tube, should be
looked for as having the same significance as the foregoing. The presence
of dilatation may be suspected when the end of the tube is not gripped,

^ Dr. J. 8. Biistowe, with oharacteristio candour, narrates a oase showing the conse-
quences which arose from a neglect of this procedure in his " Clinical I^tures and
Essays/* p. 43. The case was really one of dilatation of the oesophagus, which re-
mained undiscovered until after death.

228 THE MOUTH, TONGUE, AND GULLET [§§166,166

but is loose and easily movable. Occasionally a diverticulum or saccule
of the oesophagus is fonned, which by its pressure on the gullet above or
below it causes obstruction. In such cases a bougie, which coidd not be
passed before, may be passed after vomiting has occurred.

(c) Auscultation afiords a valuable means of detecting both the presence
and position of an oesophageal stricture. Place the chest end of a binaural
stethoscope over the interval between the xiphoid cartilage and the left
costal arch. Two gurgling sounds can be heard in this situation if the
patient swallows one gulp of fluid ; the first is when it passes from pharynx
to oesophagus, the second is when it passes from oesophagus to stomach.
The normal interval between these two is six secondsy but if there be any
obstruction in the gullet this interval becomes increased. If the first
sound cannot be distinctly heard, the moment of its occurrence can be
judged by looking at the throat. Again, by placing the stethoscope on
the left side of the neck in a healthy person a gurgling sound will be heard
during the act of swallowing. This normal sound may be traced round
and down the hack on the left side of the vertebral spines as low as the
tenth dorsal vertebrae. But if a stricture be present it will be delayed or
absent below the seat of stricture,

(d) X-ray examination with a bismuth meal is an important method
for detecting the presence of stricture or diverticulum.

§ 155. Causes of Dysphagia. — '' When a ^patient complains of difjvculty

in swaUomr^y or that the food returns to his mouthy the practitioner should

first think of thoracic aneurysm, secondly of cancer y and thirdly of some other

kind of ulceration,^' ^ The commoner causes are —

I. A tumour pressing upon the gullet from the outside.
II. Cancer of the gullet.

III. Simple or non-malignant stricture.

IV. Spasm.

V. Foreign bodies, acute oBsophagitis. and simple ulcer.

Less frequent causes are —

VI. Paralysis of the gullet.
VII. Dilatation of the guUet.

§ 156. A Tumour pressing upon the gullet from without is perhaps the
commonest cause of dysphagia, although malignant or simple stricture
and muscular spasm are regarded by many as of equal frequency. Any
intrathoracic timiour may, by its pressure, narrow the lumen of the gullet,
and undoubtedly the commonest of these is aneurysm of the aorta. Other
tumours are cancer of a neighbouring viscus, retropharyngeal abscess or
tumour, enlargement of the bronchial glands, lympho-sarcoma or other
mediastinal tumour, goitre, pericardial effusion, and diverticula of the
gullet filled with food (§ 162). The features common to all such tumours
are the slowly progressive character of the dysphagia, the symptoms of
pressure on other viscera, and sometimes, although usually not until

* Bryant, quoted by Fagge and Pye-Smith, " Prin. and Pract. of Med.," vol. ii.,
p. 316, second edition.

157, 168 ] GA USES OF D YSPHA GIA 229

late in the case, the physical signs of the tumour in question. For the
rest, the differential features vary according to the nature and position
of the tumour. In aortic aneurysm the amount of dysphagia is rarely
very great at any time, although it is slowly progressive. Rest in bed will
generally ameliorate the dysphagia. Difficulty of swallowing is only one
of the pressure symptoms in this disease, and others should be looked for —
^'9'y dyspnoea, abductor paralysis of the left vocal cord, and inequality of
the pupils. The physical signs of aneurysm are commonly wanting in
such cases on account of its deep-seated position.

§ 157. Malignant Disease of the oesophagus is due in the large majority
of cases to an epitheliomatous growth in the wall, usually primary, which
goes on to ulceration, and forms a stricture from 1 to 4 inches long. Rarely
the growth is sarcomatous. The diagnostic features of epithelioma of
the oesophagus are : (i.) The patient is past middle life. It is said to be
more common in males, (ii.) The dysphagia becomes steadily and pro-
gressively worse ; in rare cases it may be intermittent. At first a difficulty
exists only with solids, but later on fluids also are returned. The duration
of the whole illness rarely exceeds twelve to eighteen months, (iii.) Emacia-
tion and other evidences of cachexia occur quite early in the illness.
There may be evidences of cancerous deposit elsewhere, especially within
the abdominal cavity ; or there may be enlarged glands, especially above
the left clavicle, (iv.) Pain and haemorrhage, those frequent accompani-
ments of all malignant growths, are usually present and the pain is
persistent and independent of, although aggravated by, food, (v.) The
passage of a bougie is attended by considerable difficulty. The favourite
sites of malignant stricture are opposite the cricoid cartilage, 6 inches from
the teeth ; opposite the bifurcation of the trachea, 9 inches ; and at the
cardiac orifice, 16 inches from the teeth.

Fibroma and Myoma, and other benign growths in the oesophagus, sessile, or in the
form of polypi, are very rare. They may simulate simple or malignant stricture, and
there may be hsemorrhage ; but the absence of any cachexia and the long duration
without any increase of symptoms ai'e the only means of suspecting the condition.

§ 158. Simiftle or Non-Malignaiit Strictiire of the oesophagus s most fre-
quently caused either by the narrowing due to a syphilitic infiltration or
the contraction which it subsequently leaves. It may also arise from the
cicatrisation which follows a simple ulcer of the gullet or stomach ; or,
thirdly, as the result of swallowing a corrosive liquid. Dilatation may
take place above the stricture. The differential features of this condition
are : (i.) The dysphagia comes on gradually, and, having reached a certain
degree, is apt to remain stationary ; the patient may be unable to swallow
solids, but lives for many years on liquid food, (ii.) The passage of
bougies gradually increased in size is possible, and this procedure gives
some relief, (iii.) The patient may be young, or he may be of any age ;
the cachexia of cancer is wanting ; and pain is not a prominent feature
in the case, (iv.) The gullet is apt to dilate above the stricture, and the
food returns after an interval, which becomes progressively longer as the

230 THE MOUTH, TONGUE, AND GULLET [ §§ 169-161

dilatation becomes greater, (v.) There is nearly always a history of one
of the three causes above mentioned.

§ 169. Spasm of the Pharynx or (Esophagus is, in the author's experience,
one of the commonest causes of dysphagia. It is not infrequently associated
with hysteria and other functional neuroses. Its differential features are
fairly characteristic : (i.) The dysphagia is never progressive. It may
come on somewhat suddenly, dating perhaps from an emotional shock or
trouble, and it is very often intermittent, the patient being well enough
in the intervals. Sometimes solids can be taken, while fluids are regurgi-
tated, or vice versa, (ii.) It is unaccompanied by emaciation or cachexia ;
indeed, the patient sometimes appears to be in perfect health, a feature
in which it differs from all other causes of dysphagia. There is usually
little or no pain, and never any bleeding, (iii.) The dysphagia may last
intermittently for a considerable time. I have known cases persist in
varying degree for seven, twelve, and sixteen months, (iv.) The passage
of a bougie, or flexible stomach- tube, is possible with a little steady pressure,
and with the patient under chloroform it is easily done. This procedure
generally results in curing the condition, at any rate for a time, (v.) The
patient is most frequently of the female sex, and often presents other
evidences of hysteria. It certainly occurs also in males, and gout or
rheumatism are said to predispose to it.

§ . 160. Foreign Bodies, Acute (Esophagitis, and Simple I]lcer. — ^Tho
symptoms of these conditions are much alike. Acute oesophagitis occurs
after traumatism, as after swallowing corrosive fluids,^ or in a localised
form from the presence of foreign bodies. It sometimes occurs in the
course of the specific fevers, and in infants at the breast from unknown
causes. A slighter degree of localised inflammation arises by no means
infrequently when a fish-bone, needle, pin, bristle of a toothbrush, or other
solid particle, sticks in the folds of the oesophagus. This dysphagia takes
the form of a difficulty and pain during the act of swallowing, at one
particular spot. The symptoms here start suddenly and reach a maximum
at once. This source of trouble is very apt to be overlooked when the
patient has forgotten the incident which led to the lodgment of the foreign
body. When the inflammation is generalised, there is great pain, with
consequent spasm and regurgitation on attempting to swallow. Thirst
and, if the condition be severe, feverishness are present. Mucus, pus, and
blood may be vomited if idceration ensue.

Simple Ulcer of the gullet is very rare. It is sometimes due to sjrphilis.
Acute pain and tenderness are prominent features, with spasm on swallow-
ing or on attempting to pass a bougie. But the affection cannot be diagnosed
with certainty.

We now turn to the rarer cansef of Dyiphagia.

§ 161. Paralysii of the Oallet — Paralysis of the upper part of the gullet — i.e., of
the pharyngeal constrictors — is not uncommon as an accompaniment and complication

^ fluids which are simply irritating, such as boer contaminated by the substances
used to clean the pewter pots, may cause the condition.

$§ leS. IM ] PR0QN08I8 AND TREATMENT OF DYSPHAGIA 231

of diphtheria. Difficulty of swallowing under these circumstances may be ono of tho
first evidences of diphtheritic paralysis. It also occurs in Bulbar Paralysis, and at
the end of some slowly progressive exhausting diseases. All these differ from the other
causes of dysphagia by being attended by regurgitation of fluids through the noso,
owing to the paralysis of the soft palate. Paraljrsis of the gullet below the pharynx is
a much rarer condition. It may sometimes accompany and be due to the same causes
as the above. It also arises as an occasional complication of general paralysis of the
insane, cerebral tumour, diseases of the nuclei in the medulla, and lesions of the vagus.
The dysphagia in these cases is not absolute, the normal ossophageal sound on ausculta-
tion is absent, and a bougie passes without hindrance. The condition can only be dis-
tinguished from simple dilatation when there is no regurgitation or pseudo-emesis of food.

§ 162. Dilatatioii or Diverticnliim of the Gullet is not frequent, and the causes are
obscure. It may take the form of (a) generalised dilatation of the whole tube ; (6) a
fusiform dilatation above a stricture, (c) It may occur as a diverticulum., or sac,
which is said to be formed in one of two ways : (i.) A pressure diverticulum or saccule.
due either to weakness of the wall after injury, or sometimes to congenital weakness
of some part of the tube, with consequent hernia of the mucous through the muscular
wall ; and (ii.) a traction diverticulum, due either to adhesions between the cssophagus
and neighbouring glands, or other strictures, pulling out the cssophageal wall as they
contract.

(a) A general dilatation has but few or no symptoms, {b) The symptoms of form
(6) are masked by those of the stricture below. The occurrence of dilatation (with
stricture) is evidenced by the regurgitation of food at shorter or longer intervals. On
this account such oases are very apt to be mistaken for the vomiting of pyloric obstruc- '
tion {vide feature 2, § 153). There is an unusual mobility in the bougie just before it
reaches the obstruction, (c) The diverticular varieties are very rare, but, as far as
we know, their symptoms are as follows : (i.) There is regurgitation of food after an
interval varying from a few minutes to a few hours after ingestion. It is apt to be
mistaken for persistent vomiting, but the ease with which the food is returned, and
the absence of acid in it, should make us suspect this condition, (ii.) The regurgita-
tion gradually increases in amount, and the breath is foul from the decomposition of
food in the gradually enlarging pouch, (iii.) In cases of pressure diverticula a bougie
which could not be passed before can be passed after vomiting, because the sac full
of food forms a swelling that presses upon the gullet and so leads to obstruction,
(iv.) Sometimes the pouch forms a definite tumour in the neck.

§ 168. Prognosis and Treatment op Dysphaola. — Dysphagia is in
most cases a symptom of considerable gravity, and in severe cases it com-
monly enough results in death by starvation. Of all causes, malignant
stricture is the most serious, and, in spite of the means which modem
suBgery has placed at our disposal, patients rarely live more than a year or
eighteen months. The length of time depends on the maintenance of
the nutrition of the individual. Next in order of gravity come tumours
pressing on the oesophagus, when the prognosis depends on the nature of
the tumour and its amenability to treatment.

Patients with simple stricture, and with dilatation, may live for many
years on fluid diet, with or without gastrostomy, but diverticula are much
more serious. Of all causes functional spasm is the most curable, although
it is apt to return.

The cause of death in dysphagia is usually starvation or a low form of
pneumonia. This may arise from perforation into the bronchus, or by
the food passing into the glottis. In either case death is expedited by
the lowered vitality of the patient. Perforation may occur in other direc-
tions— «.gr., a case of malignant disease of the gullet under my care died
from haemorrhage consequent upon perforation into the aorta.

232 THE MOUTH, TONOUE, AND GULLET [§198

Treatment op Dysphagia. — The indications are to remove the cause
of the obstruction, to maintain the strength and nutrition of the patient,
and to relieve any concurrent symptoms. The question of three surgical
procedures may arise in these cases : the passage of bougies of different
sizes, the use of Symonds' tubes, and gastrostomy. If possible, a bougie
should be passed in all cases, not only for purposes of diagnosis, but also
as part of the treatment. It may be of little use in malignant stricture,
but simple stricture may be dilated or prevented from further contracture
by this method. Symonds' tube, a funnel-shaped tube with a string
attached to prevent it slipping down, changed every three weeks or so,
undoubtedly prolongs life both in malignant and advanced simple strictures.
An early gastrostomy offers the best chance of prolonging life in every
case of malignant stricture. In malignant stricture if, when the case
comes under treatment, debility is very marked, complications are present,
and there are evidences of cancer elsewhere, gastrostomy is the only treat-
ment of any avail. Radium is now employed with success in early cases.
In addition to the above treatment, the only indication in mcUignafU
stricture is to soothe the pain by morphia, opium, or cocaine.

In simple stricture, bougies of gradually increasing size should be

passed and left in for some hours at a time. Force must not be used in

so doing. In very narrow strictures a Symonds' tube would be better.

If syphilis be suspected as the cause, potassium iodide must be given.

IvL functional spetsm a bougie should be passed, and cold douches given

along the neck and the spine. The general condition must be treated,

valerian in hysteria, combined with special diet in cases with gastritis.

Electricity may be useful. In 'paralysis and dilatation, especially the

diverticular type of dilatation, the patient must be fed by a stomach- tube.

If the diverticulum is high up in the neck, the surgeon may be able to

remedy it. In aciUe cesophagitis the pain must be soothed by morphia

hypodermically, by cocaine lozenges, or by opium given with tragacanth.

Thirst may be allayed with spoonfuls of iced water, in which small doses

of opium, cocaine, and milk may be administered. During the acute stage

the patient may require nutrient enemata. Foreign bodies in the gullet

need prompt attention but very careful measures, else they may pierce

the tube and injure the aorta or other structures around.

Feeding hy a stomach-tvhe is a measure available in a fair proportion of cases, espe-
cially in Causes I., III., IV., VI., and VII. {supra). The only apparatus necessary
consists of a long flexible rubber tube (5 feet long) one end of which is blunt, with the
** eye " at the side or the end (according to choice) and the other end tied to a funnel.
The method of passing the tube is either the same as that used in passing a bougie
(§ 154) or it is passed through the nose. In the latter case the size must be smaller.
The operator then pours into the funnel the fluid food, previously prepared, from a
jug.

CHAPTER IX

THE ABDOMEN

The abdomen contains a large number of very important organs and
structures, but just as their physiology and pathology are in many instances
obscure, so also are the means at our disposal for their thorough clinical
investigation imperfect. However, it is in this region that we have to
deal with symptoms which on the one hand may be of quite a trivial
order, or on the other may be of extreme gravity ; symptoms and condi-
tions the issue of which will largely depend on the promptitude, know-
ledge, and skill of the medical man in attendance, and upon his adequate
comprehension of their true meaning.

PART A. SYMPTOMATOLOGY.

§ 164. Local Symptoms. — ^The symptoms referable to disease situated
within the abdominal cavity are necessarily of the widest and most varied
kind, but there are only three which are sufficiently constant to be regarded
as cardinal symptoms, all of which are referable to the abdomen itself —
viz.. Abdominal Pain, Generalised Enlargement, and Localised
Tumour.

Vomiting is a fairly constant accompaniment of all acute abdominal
conditions, whether the stomach is involved in the lesion or not. Its
causes are discussed in § 191.

The presence of Diarrhoea and Constipation depends very largely on
whether the intestinal canal is affected, and these are fully dealt with in
Chapter XI. The other symptoms also depend largely upon which of
the abdominal organs is affected, with one important exception — viz.,
" Indigestion." In all chronic abdominal disorders, no matter which
organ is affected, we are often consulted for " Indigestion " ; in fact,
nausea and all the other symptoms of pronounced dyspepsia may be due
to disease quite unconnected with the stomach, and located, for instance,
within the uterus, kidneys, liver, spleen, or pancreas. Some cases of
" dyspepsia," after resisting treatment for months or years, have been
cured by the stitching up of a dislocated kidney.

Abdominal Pain, if acute and sudden, is a medical emergency of the
most important kind ; if chronic, it presents many difficult questions for

233

234 THE ABDOMEN [ § 165

diagnosis. It will therefore merit the most careful study and analysis
(§ 168). The diseases outside the abdomen which may give rise to it are :

1. Diaphragmatic pleurisy^ or a basal pleuro-pneumonia, may give rise
to acute abdominal pain of sudden onset and to abdominal rigidity and
other symptoms of acute peritonitis, which can only be difierentiated by
the pulse-perspiration ratio and the concurrent symptoms. Pericarditis
sometimes causes severe abdominal pain.

2. Neuralgia of the intercostal and other spinal nerves may be referred
to the abdomen. In this way spinal caries, especially in children, the
crises of locomotor ataxy, and other diseases of the vertebr© or cord, may
be mistaken for various abdominal diseases.

3. An abscess in the abdominal wall, a bruise, or a ruptured muscle may
be similarly mistaken, but these shoidd present no difficulty.

4. Diabetic coma is occasionally heralded by pain simulating appendicitis.
(See a case : the Lancet, March 9, 1912.)

Abdominal Enlargement and Abdominal Tumour are considered in
Parte.

§ 165. The (General or Remote Symptoms met with in abdominal disorders
are, as just mentioned, of an extremely varied nature, and our endeavour
should be to correctly associate these symptoms with the abdominal organ
which is affected.

Collapse and Pulse-Temperature Ratio. — In connection with the
general symptoms of abdominal diseases, one fact needs special mention —
(1) the profoimd collapse which is so apt to be associated with all acute
abdominal conditions. A blow on the abdomen may result in fatal col-
lapse, and so also may perforative peritonitis. This tendency to collapse
possibly finds an explanation in the fact that the chief centre of the sym-
pathetic is situated within the abdomen. Now, a subnormal temperature
is one of the symptoms of collapse, and for this reason the temperature
rarely ranges very high even in the gravest abdominal inflammations,
especially in their earlier phases. In acute peritonitis, for instance, an
extensive inflammatory process affects the peritoneum, which acting alone
might produce a temperature of 105° F. or more, but by reason of the col-
lapse it is rarely more than 102° or 103° F. (2) In the pulse, however, we
find our best guide to the severity of mischief within the abdomen. In all
acute diseases, other than abdominal, we find a rough general proportion
between the height of the temperature and the rate of the pulse. Thus,
a temperature of 100° F. will correspond roughly with a pulse of 100, 101®
with 110, 102° with 120, 103° with 130, and so on— an increase of about
10 for every 1° F. But in acute abdominal conditions this is not so. The
pulse-temperature ratio is disturbed, for although the pulse rate increases
with the severity of the abdominal mischief, the temperature never in-
creases proportionately. Indeed, in many of the worst cases, the tempera-
ture is one or more degrees below normal. The pulse, however, is an
almost infallible guide, and one may say (1) that if the pulse remains
under 100 nothing very serious is happening within the abdomen ;

§ 166 ] PH Y8I0AL EXAMINATION 235

and (2) that the rate of the pulse and the pulse-temperatuie ratio are
great aids to the diagnosis, and in some sense measures, of acute abdominal
disorder, especially when that disorder has reference to the peritoneum.

PART B. PHYSICAL EXAMINATION,
§ 166. In the examination of the abdomen we must proceed systematic-
ally, as in the examination of the thorax, by Inspection, Palpation,
Percussion, Mensuration, and occasionally auscultation ; though of all
these measures palpation by the educated hand is at the present time
the most valuable means we have. X-rays assist in certain cases, but
this method is not always available.

1. Carefnl inspeotion of the abdomen should on no accoimt be omitted ;
much can be learned in this way. The best point of view is that from
the foot of the bed, or by bending over the patient's feet, so as to view the
abdomen from below. The mere fact of enlargement may thus be verified,
and whether the enlargement be generalised and uniform, or whether it
be localised or asymmetrical. Notice whether the umbilicus is centrally
situated, and also whether the surface presents dilated veins, such as
occur in abdominal cancer, or when the portal vein or vena cava is ob-
structed. Dilatation of the abdominal veins is met with chiefly in three
conditions : (1) In liver cirrhosis, these veins being part of the conservative
collateral circulation which gradually becomes established ; (2) the veins
without being much dilated or prominent are unduly apparent in cases
of abdominal carcinoma. It is a sign of considerable value and constancy.
(3) Extreme dilatation and varicosity of the superficial veins occurs only
when the inferior vena cava is obstructed. This is generally due to a
gummatous deposit in or around the posterior border of the liver where
the vena cava passes through it. The veins of the legs and testes generally
share to a less extent in the dilatation.^ Notice also whether there is any
thickening or infiltration round the umbilicus such as may occur in cancer
and tuberculous peritonitis. An abdominal enlargement due to the
presence of air or gas is rounded anteriorly, but when due to fluid it is
usually flattened in front and the flanks bulge ; when there is obstruction
of the large intestine the flanks bulge ; whereas in obstruction of the small
intestine low down the swelling occupies the centre of the abdomen.
Incidentally you may notice the presence or absence of the white lines
(linese albicantes) left by a previous pregnancy, the knowledge of which
may be medically useful. The presence of hernia or of tumours of the
wall may be recognised by inspection. The amount of movement of the
abdominal wall with inspiration should be noticed, for diminished or
absent movement constitutes an important sign of peritonitis. If the
peritonitis is local, the abdominal wall over that area may move badly,
whilst elsewhere abdominal respiratory movement is normal. Pulsation
may sometimes be seen, most often in the epigastrium, and may be due to

^ A case is recorded by Dr. W. Chapman. Clin. Soc. Trans., 1899 and 1900, and
Lancet, December 2, 1899.

2S6 THE ABDOMEN [ § 166

the right ventricle or an engorged liver secondary to heart failure. Some-
times aortic pulsation is unduly visible, especially in neurotic dyspeptic
women, or it may be transmitted by a pyloric tumour. Rarely the
pulsation is due to an abdominal aneurysm. Visible peristalsis should also
be looked for, and if present its position and direction should be noted.

The Regional Anatomy of the Abdomen is important as a guide to
the seat of disease (Fig. 60).

2. Palpation. — Considerable experience is necessary for satisfactory
abdominal palpation. The hand should be warmed and always laid flat
on the abdominal wall ; then by gently dipping in the fingers, by flexing
the metacarpo-phalangeal joints, we have the most ready method of
ascertaining (1) the presence of any tumour ; (2) the boundaries of some
of the solid organs. The patient should lie on his back with the knees
drawn up and the shoulders somewhat raised, so as to relax the abdominal
muscles. Do not use the tips, but only the pads of the finger, for the tips
stimulate the recti muscles to contract, and thus to simulate a tumour
where none exists. Many patients ofier considerable involuntary or
voluntary resistance, and this must be overcome by placing them in an
easy posture and distracting their attention, or asking them " to let the
breath go.'' Relaxation may be obtained by immersing the' patient in
a hot bath ; in some cases it may be necessary to use chloroform. Much
obesity is another obstacle to palpation. Palpation reveals the presence
of localised resistance and tenderness which denote underlying inflam-
mation. Tumours, flatulence, and the movement of fluid within the
abdomen can also be detected by palpation. The palpation and
percussion boundaries of the diflerent organs are described in later
chapters.

']. Percussion of the abdomen is done with the same precautions as in
the case of heart and lungs, and the student will now find it very convenient
to be able to percuss with either hand indifferently. Normally the anterior
surface of the abdomen is resonant (when the stomach and intestines are
empty) as far upwards as liver and spleen, downwards as far as the pubes,
and outwards as far as the outward border of the colon. By this means
we ascertain the presence of solid and fluid, which are dull, or of gas, which
is resonant. When the fluid is free the dulness alters with the position of
the patient.

4. By measurement we ascertain the amount of increase in size. As
a general rule, horizontal measurement should be taken at the level of the
umbilicus, and it should be recorded for future reference. In order to
ascertain whether the enlargement is symmetrical, we measure from the
umbilicus to the ensiform cartilage above and the pubes below, and from
the umbilicus to the anterior superior spine on each side. These four
measurements should be approximately equal. From these data we ascer-
tain very slight deviations from symmetry.

5. Auscultation and ausculto- percussion are useful in certain cases
to delimit the boundaries of an organ (§ 197).

PHYaWAL EXAMIXATIOX

The FALLACIES of abdominal enlargement are : (1) Fat in the ometUvm
is referred to under fluid enlargement {§ l^>). {'2) PharUotn tumtntr is de-
scribed under abdominal enlargement due to gaa (§ 183). (3) Pendulous

LeTBl of GUI Tib,
Stomach.

Oair-bluldei.

Ob[lterat«d

hrpoeuUir.

im and apptu-

SlBmold Seiure.

UruliiD.

Ulddle of Foui>art'>

Fig. 00,— RtniONg Of THE ADDOlll

EN.

1 regiona, which are bounded by

two imaginwy IIiih numlng vertically upwards on each aide ol 1

■he abdomen, from the middle ot

Ptnirart'a ligament to (be coalo-ibondral arttculmion iibiive, and f

■ 0 horiionlal line* running round

thn abdomen on a level with the end ot th» ninth co.UI cartilage

and the antcrlOT (Uperior aplnca

The right lobe ol the llvec The middle and pyloric end

The .plenic end ot the

and (be gall-bladder, the dno- of the itomacb. left lobe and

.lomach, the .pleen and e^-

deoum, pancreaa, hepatic lobulnt Spiflelll ol the Uvei,

Beiore ol the colon, upper part and the pancreu.

the splenir Heiure o( the rolon.

of the right kidney, and tbe

upper ball of the lelt kidney

The tranivsne colon, part

of the great omentum and
KtffM j.B»uar. meeenterj', traiuverM part of

Lffl Lumbar.
' DcMendina colon, part of

ol the Tight kidney, and tome volutJone ot the JelUDDm and
eonvolntiona ot the imall In- Ileum.

the omentum, lower part ol
, the left kidney, and eome con-
1 voluUona of the amall Intea-

mteatioe*. 1 Htirotalrie Rrgim.

Rw« Ili«. ln<«tl„r^il the bWdlrin

Ltjl Hit.

Sigmoid aoxure ot the colon

and ureter.

dorluf piegnancy.

abdomen, so frequent in elderly women, is often thought by the patient
to be a " tumour," but it ie due only to weakness of the muscles of the
abdomen and of the intestinal tube. (4) Pregnancy and distended bladder
are frequent causes ot error (g 188), (5) In rachitic children the liver and

238 THE ABDOMEN [ §| 167, 168

spleen may be pushed down by the deformity of the costal arches, and
so produce the appearance of an enlarged abdomen. (6) Apparent en-
largement of the abdomen may be caused by the pressure of some thoracic
tumour. (7) The most frequent cause of abdominal enlargement is the
presence of gas in the intestine.

PART a ABDOMINAL DISORDERS : THEIR DIAGNOSIS,
PROGNOSIS, AND TREATMENT.

§ 167. Boatine Frocediire and Classifleation. — ^Having first ascertained
that the patient's leading symptom is one of those above referred to, we
secondly inquire into the history, and especially whether the condition
came on acutely and suddenly, or is chronic and long-standing. The
procedure to be adopted in acute cases and that suitable in chronic cases,
will be given under their respective headings. Thirdlyy proceed to the
physical examination of the abdomen, the routine method in ordinary
cases consisting of (1) Inspection ; (2) Palpation ; (3) Percussion, to map
out the boundaries of the liver, spleen, and other organs ; and (4) Mensura-
tion. In any doubtful case the rectum, vagina, urine, and fsBces must
certainly be examined.

If severe abdominal pain, which came on saddenly and acutely, be the
leading symptom, first turn to § 168.

If abdominal pain of some duration and running a chronic course be
the leading symptom, turn to § 174.

If there be a generalised abdominal enlargement, turn to § 182.

If there be localised tumour, turn to § 187.

§ 168. Acute Abdominal Pain, coming on saddenly, includes amongst
its causes some of the most serious conditions with which the physician or
surgeon can have to deal ; and on account of the large number of organs
contained in the abdominal cavity, these causes include many pathological
processes situated in various and often unsuspected positions.

The causes of abdominal pain may be conveniently classified for clinical
purposes into nine groups :

A. Abdominal Pain coming on suddenly, with collapse.

I. Perforation of some organ or cyst (perforative peritonitis) . . § 169
II. Acute peritonitis due to causes other than the preceding . . § 170

III. Acute intestinal obstruction (hernia, intussusception, internal

strangulation, and appendicitis) . . . . . . • • § 228

IV. Displaced enlarged (or gravid) uterus ; V. embolism of the

mesenteric artery ; VI. acute pancreatitis . . . . § 171

B. Abdominal Pain coming on saddenly, without collapse.

VII. Colio^(Inte8tina], renal, biliary) . . . . . . • . § 172

VIII. Appendicitis (some cases) ; floating kidney ; splenic embolism ;

and some other obscure organic affections . . • • § 173

IX. Visceral Neuralgias . . . . . . . . • • § 173

§ 168 ] ACUTE ABDOMINAL PAIN 239

In the first six the acute abdominal pain is usually attended by col-
lapse, but not in the last three. This, however, is only relative, and in
any doubtful case the whole should be passed in review.

In order to ascertain which of these causes is in operation, and in view
of the gravity of some of these cases, it will be desirable to consider the
METHOD OP PBOCEDUBE in some detail.

(1) Regarding the cardinal or leading symptoms, inquire carefully, as
in all cases of *' pain," concerning its position, character, degree and inten-
sity. The position of the pain is not always a guide to the organ affected,
for it rapidly tends to become generalised ; but the direction in which it is
radiated is of great help in the diagnosis of the three kinds of colic. More-
over, local disease may be accompanied by generalised pain, and wide-
spread disease may give rise to a localised pain. Whenever the three symp-
toms— ABDOMINAL PAIN, VOMITING, and CONSTIPATION — come ou together
suddenly, with collapse, the condition is very probably due to either
Peritonitis (which may be due to perforation), or Intestinal Obstruc-
tion.

2. As to the History of the lUthess, it is useful to note if there had been
any illness previous to the onset of the pain pointing to ulceration, dys-
pepsia, or other derangement of the abdominal organs. The occupation
may shed some light on the cause — e.g., sudden strain, working with lead.
The description of the mode of onset may assist — e.g., "something was
felt to give way."

3. In the Examination of the Patient — (i.) his cige is an important aid
in the diagnosis of the cause of the pain. In childhood it is very probably
some intestinal affection, such as colic, or intussusception ; in adolescents
and young adults, appendicitis, while cancer and tabetic crises may prob-
ably be excluded. In adults we think of hernia and ulcer of the stomach ;
in old age after middle life we think of cancer, or if the patient is a female,
biliary colic, (ii.) The sex may aid us, for in yoimg females we may
suspect an ulcer of the stomach even without previous symptoms ; and in
older women the rupture of an ectopic (extra-uterine) pregnancy, a con-
dition which is frequently overlooked, or gall-stones, (iii.) The presence or
absence of tenderness is of considerable aid ; tenderness points to the exist-
ence of imderlying inflammation, (iv.) AU the organs of the abdomen must
be as carefully and as thoroughly examined as circumstances will permit.
Never forget to examine per rectum and vagina, because stricture of the
former or a pelvic tumour may throw considerable light upon the case,
(v.) The patient's general symptoms must also be carefully investigated.
If the temperature and the pulse be normal, we may exclude inflammatory
conditions. The temperature alone is not a sufficient guide in this respect
(see § 165), but in general terms no serious acute abdominal condition exists
without the jndse rate exceeding 90 or 100. If the patient is much emaci-
ated, in adults we must bear in mind obscure malignant disease, and in
children the presence of tubercle. Examine the urine for sugar.

If the pain, which is severe and has come on suddenly, is attended by

240 THE ABDOMEN [ § 169

marked collapse, first turn to § 169. If it is unattended by collapse, turn
first to § 172. It must be remembered, however, that any severe pain will
cause a certain amount of prostration.

I. The patient complains of acnte abdominal pain, which has come on
suddenly, tvith symptoms of severe collapse, attended by vomitinq and
CONSTIPATION ; the pulse is rapid (over 100). The case is probably one of
three conditions^ Perforation into the peritoneum, Acute PERiroNms,
or Acute Intestinal Obstruction.

§ 169. Rupture of a Cyst, Abscess, or Organ, or Perforation of the Aliment-
ary Canal (which shortly develops into Perforative Peritonitis). The cysts
which may rupture are hydatid or simple cysts of the liver, kidney, pancreas,
or other organs, ovarian and parovarian cysts, and the abscesses those of
the liver, gall-bladder, kidney or other organs, or of mesenteric glands
and perityphlitic abscess (§ 175). Rupture of an Organ, with consequent
extravasation of blood, causes similar symptoms, and of such may be
mentioned ruptured Fallopian tube (in cases of extra-uterine pregnancy),
ruptured abdominal aneurysm, rupture of the liver or kidney (following
injury). Perforation of the alimentary canal may at any time occur when
an ulcer is present. These ulcers are, in order from above downwtird,
simple ulcer of the stomach (which is usually met with in young ansemic
women), simple ulcer of the duodenum (which occurs in males), ulcer of
the lower part of the ileum (due to tuberculosis or enteric fever), ulcer
of the caecum or appendix, ulcer of the large intestine, especially the
sigmoid flexure (usually cancerous, dysenteric, or syphilitic).

Symptoms, — Pyrexia at first is absent, and the temperature may be
subnormal because of the collapse. The pulse is thready, feeble, and
rapid. The pain is probably very severe, and the ashen pallid face, with
its cold, clammy sweat and sunken eyes, is very characteristic. Vomiting
is rarely absent ; it may be incessant, distressing, and even stercoraceous.
A certain amount of constipation is generally present on account of the
paralysis of the bowel consequent on the pain. Perforated gastric ulcer
is perhaps the commonest of the conditions above mentioned, and may be
taken as a type. We should inquire for a history of dyspepsia and other
symptoms (§ 207), but in not a few cases rupture has occurred without
previous symptoms of any kind whatever. On examination there is ten-
derness, rigidity of the muscles most marked in the epigastrium, and a
tympanitic note over the whole abdomen. The disappearance of the
liver dulness in a case presenting these symptoms has been considered
pathognomonic of ruptured gastric ulcer. After a few hours there is a
deceptive period of repose, during which all symptoms of discomfort are
diminished. On examination several hours later, however, symptoms of
collapse are found with acute peritonitis (§ 170), generalised or localised.
The symptoms of perforated duodenal ulcer may be the same as those of
gastric ulcer, but the condition occurs usually in men. The symptoms of
perforation of another part of the intestine, or rupture of a cyst, are much

§ 170 ] PERFOBATI VE PERITONITIS U\

the same, and one can only hazard a diagnosis as to its situation by the
site of the pain and tenderness, and the previous history. There are three
degrees of severity met with when perforation of the intestine occurs :
(a) When there are adhesions the peritonitis may be localised or partial ;
(6) when there are no adhesions, but a small leakage, it may be only
moderately sudden in its onset; (c) when the leakage is large it is
extremely sudden and severe in its onset.

The latent feriod which ensues shortly after an acute onset deceives
many clinical observers. The pain may subside, all symptoms decrease,
and the temperature become normal or subnormal. But (1) the fulse
rate remains persistently high, and (2) in the blood there is marked leuco-
cytosis. These are sufficient to indicate immediate exploratory abdominal
section. Perforative peritonitis may have to be diagnosed from diaphrag-
matic pleurisy and pneumonia of the base, where the pidse-respiration
ratio is disturbed, but not the pulse- temperature ratio.^

Treatment and Prognosis, — ^Laparotomy should be performed at once.
If deceived by the period of repose into thinking the patient is recovering,
in a few hours general peritonitis will have set in, and operative interference
wDl be too late. In cases where patients have been operated upon within
the first twelve hours 79 per cent, have recovered ; if after twenty-four
hours only 294 per cent, have recovered (GoflEe). The after-treatment
depends on the cause. In the case of rupture consequent on injury
internal haemorrhage may take place with a rapidly fatal result, but even
in such cases early laparotomy has been performed with success.

II. The patient complains of severe abdominal pain, extreme prostration,
and voMrnNG ; there is thobacio respiration, and the temperature is
ELEVATED. The discose is Acute Peritonitis.

§ 170. Acute Peritonitis (General Peritonitis) is an acute inflammation
of the peritoneum. It is rarely a primary disease, but its onset is usually
sudden.

Symptoms. — (1) The aspect is very characteristic ; the countenance
has an anxious pinched look, the cheeks flushed, and the skin cold and
clammy. (2) The pain is severe and constant, but liable to exacerbations
on account of the intestinal peristalsis and the passage of wind along the
bowel.2 It is also increased by any kind of movement, even by the
respiratory movements. Consequently (3) the respiration is thoracic,
and careful inspection will show that (4) the abdominal walls are im-
mobile and rigid. There is acute tenderness on pressure, so much so that
the weight of the bed-clothes can hardly be borne. (5) The posture of
the patient is very characteristic as he lies on his back with legs drawn up
to relax the abdominal muscles. (6) Pyrexia, often ushered in with
sudden rigors, and attended by a small, wiry, rapid pulse of 100 to 140

^ See Report of Clin. Soc. Lond., the Lancet, April 19, 1902.
^ The aoate peritonitis which complicates enteric fever is of a latent character, and
unaccompanied by pain. This and puerperal peritonitiB are the only exceptions.

^42 THE ABWMM [ § lyO

per minute. The temperature is elevated only 2° or 3° F. above normal,
and maintained there continuously, unless pyaemia be present, in which
case there are rapid variations of wide range. In some cases — e.g., per-
foration— it may be subnormal at first {vide supra). There is marked
prostration, as in all abdominal inflammations, and a great tendency to
collapse, even from the beg'mning. (7) The bowels are constipated, and
there is persistent vomiting. Hiccough is often present, and if persistent
is a very bad sign, as in all abdominal disorders. There is diminution of
urine, which may amount to suppression. The urine is abundantly charged
with indican. Death occurs from collapse or asthenia, and the mind
remains quite clear until the end in uncomplicated cases. Peritonitis is
seldom a primary affection, and careful inquiry should reveal the cause.
. In acute localised peritonitis the symptoms are those of acute general
peritonitis, but are less severe, and are more confined to the affected region.
The Causes of acute peritonitis may be grouped under seven headings :
(i.) Injury or Operation. — ^In cases occurring in women without obvious
cause, the possibility of criminal procedure for abortion should always
be remembered. As regards surgical operations on the belly, modern
experience has shown that it is not so much the actual injury as the intro-
duction of septic organisms, which produce the peritonitis, and that if
these be excluded mere damage to the peritoneum will not cause a general-
ised peritonitis, (ii.) Extermon of inflammation from the thorax, or from
various organs of the abdomen — e.g., appendicitis, gonorrhoeal salpingitis,
inflammatory conditions of the intestines (typhoid, dysenteric, and other),
(iii.) Blood Infections of various kinds — e.g., pneumococcal, streptococcal,
staphylococcal, and gonorrhoeal. Idiopathic Peritonitis was the name
formerly given to the disease when no cause could be discovered. Peri-
tonitis is apt also to complicate scarlatina and the other acute specific
fevers. Puerperal Peritonitis is due to the introduction of a pyogenic in-
fection through the raw uterine surface. A chronic form of the disease
arises in urcemia. BactUi ccli communis may produce peritonitis either as
part of a septicaemia, or primarily, (iv.) ChiU, under certain conditions,
such as bathing during the menstrual period, is sometimes included as a
cause, though this usually leads to a chronic localised peritonitis (peri-
metritis). The true explanation of peritonitis after a " chill " is to be
found in microbic infection, (v.) Rupture of an organ or some ab-
dominal cyst, such as ovarian cyst, or an abscess of the liver, or rupture of
the gall-bladder, etc. (§ 169). Rupture of a Graafian follicle may give
rise to a monthly peritonitis, but this is usually localised and less serious,
(vi.) Perforation of some part of the alimentary canal, which had previously
become thin by ulceration — ulceration of the appendix vermiformis,
simple ulcer of the stomach (malignant ulcer rarely or never perforates
because of the infiltration around), typhoid ulcer of the ileum, etc. (see
Perforative Peritonitis), (vii.) Any condition such as volvulus, in which
the resistance of the intestinal wall to the passage of organisms is dimin-
ished, may be a cause of peritonitis, local or general.

S 170 ] ACUTE PERITONITIS 243

Acute general peritonitis has to be Diagnosed from four diseases :
(1) Acute intestinal obstruction, in which the constipation is absolute and
no flatus is passed ; there is usually no pyrexia, and the constitutional
disturbance is usually less. (2) In coliCy although the pain is also very
severe, there is an absence of tenderness, and pressure may give relief.
Pyrexia and collapse are absent, and the pulse is normal. (3) In catarrhal
enteritis there is pain, and there may be vomiting and tenderness on
pressure, but in this disease there is profuse diarrhoea. (4) In certain
cases of hysteria, acute peritonitis may be very accurately simulated,
though the temperature and pulse aie normal, there is very little collapse,
and there are evidences of the hysterical stigmata.

The Prognosis of general peritonitis is always very serious. As regards
etiology, perforative peritonitis, formerly considered the gravest, is prob-
ably now the most hopeful if promptly dealt with. Modem surgery has
done much for the rescue of such cases, and undoubtedly the most favour-
able of them is that due to appendicitis. Cases of this disease, if properly
managed, should hardly ever be lost. The prognosis in any particular case
depends therefore on the time elapsing before operation, and secondarily
on the cause and the severity of the collapse, the dyspnoea, and the
hiccough.

Treatment, — The treatment of acute peritonitis depends upon whether
it is general or local. If general, the only rational treatment is by opera-
tion immediately a diagnosis has been made. A fatal issue is almost
invariable in cases not operated upon, since the condition is rarely primary,
and a definite local lesion is usually present. If for any reason an opera-
tion cannot be done, recourse must be had to the older methods of treat-
ment. In local peritonitis medical treatment is indicated, but even in
this condition, if there are signs which make it probable that pus has
formed, an exploratory incision should be made. Medical treatment com-
prises keeping the patient in bed and relieving symptoms. The diet should
be fluid, consisting of soups, jelly, milk, to which stimulants may be added
according to the condition of the pulse. Rectal feediiLg may be necessary.
Local applications may give relief, especially cold in the form of icebags,
or ten or twelve leeches to the abdomen. Fomentations, either simple or
with tincture of belladonna, relieve the pain. The most valuable drug is
opium, for it relieves the pain, and reduces the peristalsis of the bowel,
and so gives local rest. It may often be given in fluid form by the
mouth, and can be tolerated in large doses. If vomiting persists it should
be administered h3^odermically. If there is any doubt as to the advisa-
bility of a surgical operation, either immediately or later, opium should
be withheld, for by masking the symptoms it may lead to a continuation
of medical treatment when operation is called for. It is therefore of use
chiefly in local peritonitis, or in general peritonitis where an operation is
not permitted. Purgatives are better avoided, but the lower bowel should
be opened by means of enemata. The hiccough may be relieved by giving
ice to suck, and by opium or chloral.-

244 THE ABDOMEN [ f 171

III. The jxUient complains of acute abdominal pain which is attended
by coUapsey and the pulse is bapid ; there is absolute constipation,
tinth inability to pass even flatus, and vomiting (at first of food, then of bile,
and finally of stercoraceotis matter) — the condition is Acute Intestinal
Obstbuction.

Acute Intestinal Obstruction — i,e., obstruction coming on suddenly, is
always a matter of serious importance, and every practitioner should be
thoroughly acquainted with its several causes. In actual practice, when-
ever the three symptoms, constipation, vomiting, and abdominal pain
occur together, one of three conditions should be suspected — ^acute peri-
tonitis, intestinal obstruction, or colic.

The various causes of acute intestinal obstruction — the chief of which
are External Hernia, Internal Strangulation, and Intussusception — are
fully dealt with under Intestinal Disorders (Chapter XI.). Appendicitis
is mentioned by some as a cause of intestinal obstruction. Appendicitis
may first present itself as an acute disease ; it is described in § 175.

§ 171. The patient complains of acute abdominal pain, with more or less
collapse ; the temperature is probably normal or subnormal, but the symptoms
do not quite conform to any of the preceding — some of the rarer causes are
probably in operation, such as the following :

IV. Diiplaoement of a Ora?id Uterus is known by the pain being referred to pelvis,

and examination revealing the local mischief. It may occur when jumping from a
height, and performing active exercise, espeoiaUy in early pregnancy (Chapter XIV.}.

V. In Embolism of the Mesenteric Artery, a cause of embolism, such as endocarditis,

is present. It is rarely diagnosed during life. The absence of symptoms pointing
to the other causes may lead one to suspect embolism. Embolism of the sjileen may
also cause severe symptoms.

VL Acute Pancreatitis. — (1) The pain here is very sudden and severe, usually in
the upper part of the left side of the abdomen ; (2) vomiting and constipation are
usuaUy present ; and (3) there is usually tympanitic abdominal distension (see also

S 181).

Via. HsBmorrhage into the Pancreas is attended by : (1) severe and sudden pain in
the upper part of the abdomen, and that part soon becomes tender ; (2) vomiting of
increasing severity ; (3) symptoms of collapse, with the restlessness and subnormal
temperature which accompany collapse when it is due to haemorrhage (§ 181).

The Diagnosis of both of these conditions from intestinal obstruction or peif oration
into the peritoneum is usually impossible before laparotomy. In both diseases death
f it)m collapse is the usual result.

VI 6. Acute inflammation (adrenalitis) or haemorrhage into the suprarenal capsules
X>roduce8 symptoms similar to those of acute pancreatitis. There is sudden abdominal
(epigabtric) pain, with vomiting and collapse. Death may occur in a few days. Or
there may be convulsions and coma, or extreme muscular weakness for some days
before death. It is rarely diagnosed during life.

YII. The patient, whUe apparently in good health, complains of acuta
abdominal pain, which has come on suddenly, withoat definite oollapse;
the pulse does not exceed 1(X) ; there may be vomiting and conslipcUton,
The case is probably one of the three kinds of Colic, though Appendicitis,
Visceral Neuralgia and some other affections may start in
this way.
' § 172. Crolic is a somewhat vague term applied to spasmodic paroxysmal

im]

COLIO

245

pain situated in the abdomen. There are three kinds — ^intestinal, hepatic,
and renal colic — and they have the following features in common : (1) The
pain is extremely severe, and sudden in its onset ; (2) not infrequently
there is vomiting from the severity of the pain ; (3) the face is pale and
** anxious," and in severe cases the pulse is rapid and feeble, though it
practically never exceeds 100 ; (4) the temperature is neither above nor hdow
normal ; (5) the physical signs in the abdomen are negative, and the pain
may even be relieved by pressure. In intestinal colic a hardening of the
bowel may be appreciated by the palpating hand.

(a) Intestinal Ccdio is due to distension and spasm of the bowel. The
pain of intestinal colic is characteristically twisting, paroxysmal, and
limited to the abdomen, principally around the umbilicus, and is relieved
by pressure which distinguishes it from peritonitis. The abdomen may
be distended with flatus. Sometimes it is followed or accompanied by
diarrhoea, or, as in lead colic, by constipation. The pain of colic due to
lead-poisoning may be the first sign of lead-poisoning, or may be accom-
panied by a slow, hard pulse, with other sjrmptoms of plumbism, such
as a blue line on the gums ; and a history of working amongst lead is
obtainable (§ 405).

(6) In Hepatic Crolic which is due to the passage of a gall-stone into the
bile duct, the pain shoots upwards to the right shoulder and backwards,
never downwards ; a dull pain continues during the intervals between the
spasms. After lasting a few hours or a day or two it is followed by jaun-
dice. A history of previous attacks assists the diagnosis.

(c) Renal Ccdic is due to the passage of a calculus along the ureter.
The pain radiates dovmwards from the loin to the thigh and the testicle of
the same side, which is often retracted. It may last for a day or two.
During the attack micturition is frequent ; sometimes there is hsematuria
or strangury. There will probably be a history of gravel in the urine, or
attacks of a similar nature.

The Diagnosis of the forms of colic is given in Table XIII.

Table XIII.— Dugnosis of Colic.

Charader and DittribtUion
of Pain.

Intestinal.

Biliary.

Banal

Aitoeiated Symptoms,

Twisting, around umbiU- j Constipation (or diarrhosa).
cus, paroxysmal ; re- No jaundice,
lleved by pressure.

I In right bypochondrium
shooting upwards to right
shoulder, constant, but
also in paroxysms.

In loin, shooHng down to
thigh and testicle or
ovary of same side.

Jaundice soon supervenes.
Other hepatic symptoms
may be present.

Crjrstals or other urinary
change, hsematurla. Xo
jaundice. Sometimes
frequent micturition or
strangury.

Age and Sex of
Patient.

Any age or sex.
Sometimes evi-
dence or history
I of plumbism.

, Female sex. At or
after middle life.

Usually male. Chil-
dren and adults.

246 THE ABDOMEN [ {{ 17S, 174

Prognosis, — The course of an attack of colic is short and severe.

Treatment. — ^Por all fonns of colic some of the following measures — ^hot
fomentations, a hot bath, belladonna, turpentine, opium, or chloroform,
as local applications, and hypodermics of morphia (gr. ^, with atropin
gr. vV) — ^^7 ^ necessary to alleviate the extreme pain. Large draughts
of warm water shotild be taken. For intestinal colic in particular, a full
dose of castor oil, with 20 minims of laudanum, should be given, followed
by saline purgatives. For lead-poisoning, see § 405. Hepatic colic is
treated under gall-stones (§ 241) and renal colic (§ 301).

§ 178. Vni. ^rnong the rarer cantei of aoale aHominal pain without oollapse are
Tarious OBscuBE OBOAino AFFECTIONS of the abdomen, evidenced at first only by
pain. Two may bo mentioned which came under my notice, Pangrsatio Galcui«us
and Obtubatob Hebkia, in both of which the only symptom for some time was pain
coming on suddbkly without collapse. In the former the pain was extremely severe,
and of a paroxysmal character, situated just below the umbilicus ; later on it was
associated with fat in the faeces, emaciation, and glycosuria.

Dislocated or Floating Kidney (§ 177), which is a moro frequent condition than
Is usually supposed, may be attended by a constant (chronic) pain, or give rise to
severe attacks (Diotl's crises), hardly distinguishable from intestinal colic.

Appendicitis is also a cause of abdominal pain, which may be of sudden onset
Sir William Macewen told me of the case of a young man who was suddenly seized
with severe abdominal pain in jumping out of a hansom cab. But appendicitis is
rarely so acute, and is therefore treated of more fully in § 175.

In Splenic Embolism the pain is generally sudden in onset, but is not usually
very severe or lasting, and is referred to the splenic region. Its most common cause
is acute or chronic endocarditis, evidences of which are present (§ 47).

In most obscure organic affections the pain comes on gradually, and is of a
chronic character. Acute pain occurring in attacks of varying duration is met with
in oases of membranous or mucous Colitis, and the Viscebal Neubalous.
Diabetic Coma is sometimes heralded by pain, usually in the epigastrium, which may
be very severe (§ 164).

IX. In Viioeral Venndgin abdominal pain may come on suddenly and acutely,
and may be for a long time the only symptom.

1. Ofutralgia, or gastric neuralgia, is rare, but it is the most typical and best-known
visceral neuralgia. The pain is severe, periodic, but usually relieved rather than
Aggrav&ted by food or by pressure. The skin may, however, bo very sensitive to the
flick of a handkerchief (§ 206).

2. The gastric crises and neuralgia of the bladder or other viscera in association
with tabes dorsalis,

3. Neuralgia, or *' colic " of other viscera (i.e., pain in the viscus without functional
or organic derangement), have been described by various authors — e.^., ovarian colic,
vesical or splenic neuralgia, etc. — though these cases sometimes turn out to be con-
nected with an undiscoverable organic disease, or with tabes dorsalis,

4. The neuralgia which accompanies or follows herpes zoster.

5. Angina Pectoris Is in some oases referred more to the abdomen than it is to the
chest, but it is recognisod by the circulatory disturbances, etc. (§ 41).

6. Migraine is certainly met with, alternating with abdominal pain.

§ 174. By Chronic AMowinal Pain I mean that kind of abdominal pain
which has come on somewhat gradually, and is running a chronic course.
Chronic abdominal pain may be produced by a large number of causes
which it would be impossible even to enumerate. It is only possible here
to refer to those conditions which do not psssxnt signs or symptoms
distinctly pointing to scone affection of the stohaoh, tiVER, spleen, or

§ 175 ] CHRONIC ABDOMINAL PAIN 247

other ABDOMINAX viscus. Abdominal pain is the leading or only symptom

in the following conditions :

L Appondioitis . . . • . . . . . . . • • • § ^^^

II. Chroixio intestinal obstniotion (malignant strictnie, simple strioture,

pressure by a tumour, paralysis of the bowel, etc.) . . . . S 229

III. Chronic peritonitis . . . . . . . . • • § 176

IV. Movable kidney . . . . . . • • § 177

V. Intestinal dyspepsia; VI. Enteroptosis ; VII. Obscure visceral and

spinal disease ; VIII. Pancreatic disease . . . . §{ 178-181

The history must be thoroughly investigated, and every organ thoroughly
examined. Three features may afford us important clues :

1. The POsmoN, character, degree, and constancy of the pain, and the presence
of tendemew must be observed, (i.) If the pain and tenderness bo generalised, one
may suspeot Tubercle or Cancer of the Peritoneum, (ii.) If they be situated chiefly
in tho lower abdomen, one may suspect Appendicitis or incipient disease of the
Bladder or Uterus, (iii.) If the pain be chiefly in the upper abdomen, incipient Gastric
or liver disease. Thorough and espsatbd examinations of the abdomen, rectum,
and vagina are nearly always necessary. The urine also should be repeatedly examined
for gravel, etc., and the fceces (§ 215) for gall-stones. If there be general abdominal
enlargomont, turn to { 182 ; if a localised tumour, turn to § 187.

2. The AGS of tho patient, and the history and duration of the illness should be
inquired into. In children perhaps the commonest of the obscure causes of chronic
abdominal pain are intestinal worms and tuberculosis of tho peritoneum ; in the aged,
incipient cancer of some organ.

3. The STATS or thx bowsls, both previously and at the time of examination.
In I., U., and III. above there is constipation, while in most of the other causes there
is diarrhoea or irregularity of the bowels.

The Abdominal Pain U constant^ hut liaUe to exacerbations, especially
after exercise ; there is tenderness in the right iliac region ; the pulse is
RAPID, and the temperature elefxited from time to time ; the patient is
young. The disease is probably Appendicitis.

§ ITS. Appendicitifl is much more common than used to be suspected,
yet it is still frequently overlooked, especially in chronic cases. Appendi-
citis may consist simply of a catarrhal inflammation of the vermiform
appendix, which may go on to Ulceration, Peritonitis (usually localised),
or Perforation, If it subsides, there is usually left some degree of inflam-
mation which may be insufficient to cause appreciable symptoms, yet
predisposes to attacks of a more acute nature. Acute appendicitis is often
associated with an impaction in the appendix of intestinal concretions,
which may have formed around some foreign substance such as a fruit-
stone or toothbrush bristle. Inflammation may extend to the csBcum
(typhlitis) or the surrounding tissues (perityphlitis). If the lumen is
blocked, as by any foreign body, an abscess forms in the tip of the appendix,
with localised peritonitis. If the disease subsides at this stage, adhesions
are formed which, when they contract, may kink the lumen and give rise
to another attack. The inflammation may go on to ulceration and per-
foration, and a localised peritonitis, again with the formation of adhesions,
may result. On the other hand, adhesions due to a former attack may
not be dense or widely distributed enough to prevent the occurrence of a
generalised peritonitis. If the localising inflammatory reaction of tho

248 THE ABDOMEN [ 1 176

peritoneum is adequate, an abscess will form, and may give rise to very
few symptoms, or may gradually extend until its subsequent treatment
becomes very difficult and fraught with grave danger to the patient.
The results of such extension, which may be very slow or extremely
rapid, are subdiaphragmatic abscess, pyosalpinx, rupture into the bowel
or bladder, or externally above Poupart's ligament. It is very rarely
now that cases are allowed to reach such an advanced stage that the last
complication can occur. In acute cases the complications most to be
feared are general peritonitis, perinephric abscess, and implication of the
liver by spread along the vessels or lymphatics.

There are two clinical forms of appendicitis : Acute or recurrent, and
chronic appendicitis, (a) In Chbonic AppENDicrris there may be no
symptoms other than pain in the right iliac region increased after any
over-exertion. Sometimes the pain is referred to another part of the
abdomen ; sometimes there is also alternating diarrhcea and constipation ;
there may or may not be local signs of swelling or tenderness, and a history
of general malaise. One form of chronic appendicitis is due to malignant
disease or tuberculosis of the appendix.

(6) Recurrent Appendicitis consists of recurring acute attacks. Here
again the course of the disease is essentially a chronic one, with a constant
liability to a recurrence of the inflammation. After this has subsided the
patient may go on for many months in apparent health. Possibly he may
never be troubled again, but in the vast majority of cases a fresh attack
of inflammation occurs sooner or later.

Symptoms, — ^In a typical acute attack of appendicitis there are three
symptoms, which, occurring in a young person, point to appendicitis —
pain with tenderness, local resistance or swelling, and quickened pulse.
(1) The chief symptom, as above mentioned, and sometimes the only one,
is pain with tenderness, usually situated in the right iliac region. The
tenderness is generally fixed, and is nearly always in this situation ; but the
pain has a tendency to radiate, and it may be referred to the umbilical, or
even to the left inguinal region. Special tenderness is present at " Mac-
Bumey's point" — i.e., midway between the umbilicus and the right
anterior superior iliac spine. (2) There is a feeling of resistance or rigidity,
or an indefinite tumour, with dulness to percussion, in the right iliac fossa.
This local swelling may be due to abscess formation or to septic infiltration
of the subcutaneous tissues. (3) The pulse is quickened and thready. It
forms the best single indication of the acuteness of the progress of the
attack. The temperature very often falls with the onset of gangrene, but
the pulse, except in very rare cases, remains rapid. The temperature
usually rises soon after the onset of the pain, and remains about 100^ to
102*' F. for a few days (Fig. 106, § 384). (4) Vomiting may be urgent at
the onset of an attack ; when it continues for many days the prognosis is
imfavourable. Constipation is usually present, so that the case is apt to
be mistaken for intestinal obstruction ; but in some cases the attack is
ushered in with diarrhoea. The urine is scanty, and the bladder irritable.

§ 176 ] APPENDICITIS 249

Course and Prognosis. — When an acute attack, as above described, sets
in, there are three possible events — recovery, local abscess formation, or
general peritonitis. (1) In a favourable case the temperature falls about
the third day, the swelling disappears, pain and other symptoms subside,
and the patient may be well in ten days. In other cases slight fever per-
sists for a few weeks, and there is left an indurated swelling due to adhesions.
The patient may go about for months or years with chronic appendicitis,
and apart from vague pains, general malaise, and dyspeptic symptoms
suffer no inconvenience. At any time, however, he is liable to have a
recurrence of the acute symptoms. (2) When the general symptoms show
no improvement by the third day, and the local swelling progressively
increases, it is probable that an abscess is forming. (3) Perforation, with
generalised peritonitis, may occur at any time. The general symptoms
in such cases are much more severe, vomiting persists, and the abdomen
is distended and motionless by the second or third day. There is no
disease in which it is more dangerous to hazard a prognosis. An appar-
ently convalescent case may develop general peritonitis and die within
twenty-four hours ; on the other hand, a case presenting every sign of a
large and extending abscess may clear up entirely and prove free from any
subsequent attack. Apart from the great improvement in the prognosis
when immediate operation is performed, the only indications of value
for the purpose of forming an opinion are the condition of the patient as
regards shock, collapse, and age. The younger the subject, the more
likely is the disease to prove fatal.

Treatment. — Rest in bed and light diet are essential. Hot fomentations

locally are useful for the pain. Opium in small doses (short of causing

drowsiness) is also admissible for the relief of pain after the diagnosis is

established. It should not be given for long, as it confines the bowels.

Other hypnotics may be employed. *

The question of operation requires careful consideration, and a surgeon should be
early in touch with the case. The largest proportion of recoveries is recorded in cases
operated on within twenty-four hours of the onset of symptoms which enabled a
diagnosis of appendicitis to be made. The subsidence of symptoms is not necessarily
a oontra-indication to operation. The onset of gangrene, in particular, may cause a
sudden subsidence of all signs of acute disorder ; even the pulse rate may return to
within normal limits. The most valuable sign, in the absence of clinical indications,
is the presence of a leucocytosis. If this goes above 20,000, or is found to be rising
when two or more estimations are made at intervals, there is so strong a presumption
of pus formation that immediate operation is indicated. If, by this or by other moans,
the presence of pus is diagnosed, operation must not be delayed. Delay for even a
few hours, as, for instance, when the patient or his friends are unwilling that he should
be removed to a hospital or home ** until the morning," has on many occasions proved
fatal from the onset of collapse of such severity that the patient's strength was not
sufficient to carry him through even the shortest operation.

In addition to chronic abdominal pain, there is a history of constipa-
tion, gradually increasing to complete stoppage of the bowels, with the
gradual supervention of vomiting. The case is probably one of Chronic
Intestinal Obstruction.

260 THE ABDOMEN [ § 176

In Chronic Intestinal Obstniotion (§ 229) the abdominal pain is more
or less generalised and intermittent. The constipation may at first have
alternated with diarrhoea, but after a time it is so complete that not even
flatus can be passed. Vomiting, at first of food, and later fseculent matter,
a rapid pulse, and other constitutional symptoms ensue if the condition
is not relieved. The four commonest causes are Malignant Stricture,
Simple Stricture, Pressure of a Tumour, and Paralysis of the Lower Bowel.

The abdominal pain is chronic and generalised ; it is attended hy

CONSTITUTIONAL SYMPTOMS, and SOme ABDOMINAL ENLARGEMENT OT Other

local signs. The disease is probably Chronic Peritonitis.

§ 176. Chrohic Peritonitifl nms a slow and chronic course, and is usually
attended by a certain amount of generalised pain. There is a simple or
idiopathic chronic peritonitis, but two more frequent forms are : (a) That
due to tuberda, and (6) that due to cancer — two conditions which, by the
way, are met with at the opposite extremes of life, and which present a
very marked contrast both in their clinical and anatomical features.

In Chronic Tuberculous Peritonitis (tuberculosis of the peritoneum,
abdominal tuberculosis) the patient is nearly always a child. There is a
deposit of tubercle in the peritoneal tissues, and the intestines become
matted together hy adhesions. Sometimes fistulous openings form between
different portions of the bowel. (1) Pain and tenderness are present, but
are not very marked features, except during one of the subacute or acute
exacerbations which arise. (2) Tuberculous peritonitis is contrasted with
cancerous peritonitis by its marked tendency to the formation of adhesions
without fluid, while in cancerous peritonitis there is effusion of fluid without
adhesions. As a consequence of the adhesions and the deposit of tubercle,
knots or thickenings can be felt through the abdominal walls, which have a
very characteristic doughy or " boggy" feeling. (3) Fluid may be present
when the disease occurs in young adults, and in acute cases. As the
disease advances there is considerable tympanitic distension. (4) Local
tumours may be felt in some cases, the most characteristic being a sausage-
shaped band produced by the rolled and infiltrated omentum running
transversely across the abdomen below the edge of the liver. Hard
tuberculous masses can often be felt aroimd the umbilicus. Other tumours
are produced by matted mesenteric glands or cystic collections of fluid.
(5) There are emaciation and hectic fever — i.e., morning temperature
normal and an evening rise of 2° or 3° F., as in all active tuberculous
processes. (6) Tubercle is generally found in other parts also, especially
in the lungs. (7) In one form of this disease in children a tuberculous
abscess forms, which points at the umbilicus, and gives rise to a fersistent
discharge from the navd {/cecal fistiUa),

Diagnosis. — The acute variety, especially when active near the caecum,
suggests appendicitis, but is recognised by the course of the disease.
Cirrhosis of the liver is rare in children, and in adults tuberculous
peritonitis is rare ; both may be overlooked. In the latter jaundice and

S 177 ] ^ CHRONIC PERITONITIS 251

dilated umbilical veins are absent, and rectal examination may detect
enlarged glands. A positive tuberculin test assists diagnosis in difficult
cases. The ascitic fluid in cirrhosis contains chiefly endothelial cells ; in
tuberculous peritonitis Ijonphocytes predominate. Inoculation of guinea-
pigs with the fluid is a crucial test.

Prognosis and Treatment, — The prognosis is very serious, though not
so bad as formerly. Much may be done by treatment on the same lines
as for pulmonary tuberculosis. Sedatives may be used if much pain be
present. If the temperature is raised, the patient should be kept in bed.
Guaiacol, thiocol, and iodide of iron are the most useful drugs. The
abdomen should be kept at rest by bandaging, and rubbed with blue oint-
ment. Starchy foods causing flatulence should be prohibited. Tuberculin
treatment has been tried. Laparotomy is contra-indicated in generalised
peritonitis, but is called for where there is local abscess formation.

Chbonic Cancerous Peritqnitis (Cancer of the Peritoneum) is always
attended by much pain, constant, but also in paroxysms. There is a
great tendency to the rapid formation in the abdominal cavity of fluid
which is nearly always tinged with blood. It arises only in late middle or
advanced life. Its recognition is easy in typical cases on account of the
age, acute pain, and ascites (under which heading it is described, § 185).
Sarcoma of the peritoneum is rare.

Chronic PsitiTOinns of the simple or idiopathic type is very difficult to diagnose
in the majority of oases, because of the extieme variability and vagneness of the
symptoms. (1) Pain and tenderness, sometimes localised, are present, worse at times
and with exertion ; (2) dyspepsia, often constipation, sometimes vomiting ; (3) malaise
with pyrexia from time to time ; (4) palpation may detect localised thickenings and
areas of resistance ; (5) ascites is present in some cases ; in other cases it is absent,
and the abdomen is very flat.

Etiology, — (1) After an attack of. acute peritonitis ; (2) inflammation of any organ
may cause localised peritonitis ; (3) after paracentesis without strict asepsis ; (4) idio-
pathic, due to unknown causes. It may occur with Bright's disease and other general
conditions, in which two or more of the serous membranes (pleura, pericardium)
become simultaneously affected (polyorrhomenitis or polyserositis).

The Diagnosis has often to be made by a process of exclusion, especially when
there is no history of acute peritonitis nor of inflammation of any organ. Sometimes
it is indistinguishable from tuberculous and cancerous peritonitis. Abdominal pain
simulating gastralgia or colic may be due to peritoneal adhesions. When ascites
reappears after repeated tappings peritonitis is usually present.

The Prognosis as to life is good in mild cases, though chronic invalidism is apt to
ensue. Subacute attacks are liable to occur, and there may be great exhaustion and
emaciation from involvement of some part of the alimentary canal, or from the
formation of local abscess. Adhesions may lead to intestinal obstruction.
. Treaknent, — Rest and supporting belts may give relief. Inunction with blue oint-
ment or applications of Tr. Iodine (1 in 3 of water) are useful. Paracentesis and
surgical treatment may be required.

The pain is of a ^*^ dragging " character y increased by exertion, accom-
fanied by dyspeptic and oAer vague symptoms. The disease is possibly
Dislocation of the Kidney.

§ 177. Movable Kidney (also called Dropped, Dislocated, or Floating Kidney,
according to the degree of mobility). — ^This condition is by no means uncommon, and

262 THE ABDOMEN [ § 178

does not usually givo rise to symptoms unless the degree of mobility is oon-
siderable.^

The Physical Signs can only be discovered by palpation of the abdomen, with the
patient lying down. The method of palpating the kidneys is given in § 292. With
the patient in the erect or sitting posture, the ^dney comes down more during inspira-
tion than when lying down. After a little practice she will be able to lean forward
and relax her muscles, which is an important aid to the observer. The left kidney
rarely falls below the umbilicus, but the right one may be displaced into the iliac
fossa, and even into the pelvis.

Symptoms. — In a few cases two kinds of pain may be experienced : (a) A constant
dull, dragging pain in the back, or perhaps only an uneasiness in the loin, radiating
down to the groin and inner side of the thigh, relieved by rest ; (6) attacks like renal
colic, which may be followed by the passage of blood and albumen, and are due to the
kinking of the ureter. Such are called " DietFs crises." Sometimes hydronephrosis
results. Neurasthenia is often associated, with mental depression or symptoms of
dyspepsia, vertigo, diarrhoea, or constipation.

Etiology, — ^The fact that a very much larger percentage of women than of men
have movable kidney is attributed by Suckling to the wearing of corsets. A fall or
strain will also displace the organ, and that is why it is advisable for those with spare
abdominal muscles to wear a belt when at work in the gymnasium. Attendants at
refreshment bars, who have to draw beer or draw corks often suffer from movable
kidney. It is said to be extremely common among those who suffer from migraine
(owing possibly to the retching which is a feature of that condition), and it occurs more
often in tall than in short people. Rapid loss of fat, or lowering of the intra-abdominal
pressure, such as occurs after delivery, are frequent causes.

Treatment, — Bromides and rest will relieve the patient for a time, and any con-
current dyspepsia must be remedied ; but the radical treatment consists either in
the wearing of a proper form of belt, or an operation for stitching up and attaching
the kidney in position. The abdominal belts usually supplied by instrument makers
are not very successful, but Suckling has designed an apparatus ^ for applying additional
pressure outside the belt, which he claims does away with the necessity of operation,
and is permanently successful. Fattening of the patient is often a successful means of
relieving the symptoms.

Among the rarer oaosM of chronic abdominal pain may he mentioned Visoerai«
Nbubalols (§ 173), Intestinal Dyspepsia, Entbboptosis, Incipient Spinal or
Visceral Disease, and Disease of the Pancreas.

§ 178. Inteitinal Dyspepiia and Intei tinal Catarrh are conditions which it is some-
times difficult to distinguish, and some doubt whether they ought to be described as
separate entities. The patient complains of obscure and erratic pains in different
parts of the abdomen, and of irregular attacks of diarrhoea and constipation brought
on by slight dietetic errors or exercise. There is generally a good deal of flatus passed
per rectum ; the faeces are offensive, very often fermenting, and contain a good deal of
undigested food. When there is rectal or intestinal catarrh, there is a certain amount
of mucus (see § 215) and specks of blood (not streaks, such as come from piles) in the
faeces. Excess of inorganic ash in the faeces points to catarrh, especially of the colon.
There may be prostration, nervousness, and ready fatigue. The disease is inconvenient
and often intractable. In view of the large number of organisms normally found in
the intestinal contents, any continual damage of the intestinal wall is to be deprecated,
since the bacilli can more readily make their way through a damaged wall, and in this
way give rise to what used to be called idiopathic peritonitis and other troubles.

Treatment. — ^The indications are : (1) To prevent the decomposition in the intestines ;
(2) to allay the catarrh. Forbid those articles which are not digested. In some, fruit
and vegetables cause the dyspepsia ; in others, carbohydrates. The patient may
derive benefit from diet consisting entirely of boiled milk for a time. Constipation
should never be allowed ; castor oil (which can be given in capsules) is useful Intesti-
nal antiseptics are beneficial, such as salol and salicylate of bismuth. Enemata or

1 Dr. Hector Mackenzie, the Lancet, vol. i., 1907, p. 1362, and vol. ii., 1907, p. 1140,

2 Supplied by Messrs. Salt, of Birmingham.

§S 179, 180 ] ENTEROPTOaia 263

large antiBoptio intestinal douches (3 to 5 pints) are given once a week in ohronic oases
with excellent results. (See Colitis, § 221.)

§ 179. Enteroptoiii (synonyms : visceroptosis, Gl^nard's disease, abdominal ptosis,
dropping of the viscera) is a condition in which there is a general ptosis, or downward
displacement or dropping of one or more of the movable abdominal viscera. Any of
the viscera may be dropped in this way, owing to laxity of their ligaments or mesentery
— ^liver, spleen, kidneys, and even intestines (Gl^nard). In many oases no symptoms
are present. The most constant are : (1) Pain or a sense of weight or dragging in
the abdomen, and sometimes in the back, accompanied by a feeling of sinking, or of
emptiness or hollowness, is frequently present. ITrom time to time the pain may
assume a colicky character. It has been noticed in many cases that there is tender-
ness at a localised spot a little to the left of the middle line, just above the level of
the umbilious. (2) There is generally nausea, and from time to time vomiting.
Symptoms of dyspepsia are usually present. (3) Sometimes there is diarrhoea, but
more often constipation, and it is a special feature that aperients seem to cause con-
siderable distress. (4) Groat depression, nervousness, a general unfitness for all forms
of exertion, and, indeed, all the symptoms of neurasthenia, may ensue, and the
patients are apt to drift gradually into hyperohondriasis. (6) The examination of the
abdomen should be made while the patient is standing erect. The position of the
viscera should then be marked, and afterwards an examination should be made with
the patient in a recumbent posture. X-ray examination after a bismuth meal its
used to reveal ptosis of the intestine or stomach. In marked cases the symptoms
are considerably aggravated by the erect position, and they may be relieved by
lying down, by pressing on the lower abdomen, or by wearing a supporting bolt.
Undoubtedly in many cases a displacement of the viscera can thus be made out,
and when the patient is upright, a normal sized liver, or even a kidney, may be mis-
taken for a tumour.

• The Prognosis as regards recovery ia very uncertain. On the other hand, the
condition is not fatal, and much can be done by judicious treatment if the physician
secures his patient's confidence. The lives of these patients are often very miserable.

Treatment. — The indications are : (1) To relieve the nervous symptoms ; (2) to
relieve the dyspepsia ; (3) to support the viscera. Much relief may be derived from
wearing a well-fitting, adjustable abdominal belt. Flannel is the best material if
the patient's skin tolerates it. The treatment of the neurasthenic symptoms and
dyspeptic symptoms respectively is given elsewhere (Chapter X.). In severe cases
which resist milder measures the idea of operative procedure should certainly bo
entertained. Cases have been recorded in which all the symptoms disappeared after
a simple abdominal incision, and the subsequent compulsory rest. In other cases
definite organic lesions were found within the abdomen, which had not been detected
during life, and which apparently caused the displacement.

i 180. Incipient or Obicnre Viiceral or Spinal Diiease. — (a) In oases of chronic pain
QEKEBAUSED ovEB THB ABDOMBN, and in the absoncc of constipation, diarrhoea, or
any of the causes mentioned under § 174 onwards, one might suspect cancer of the
intestines, of the pancreas, or of the kidney, cancer or tubercle of the supraronals
(i.e., Addison's disease, in which pain over the stomach is a constant sign), or other
incipient disorders, rheumatism of the abdominal muscles, enteroptosis, or movable
kidney. Children may su£fer from recurrent attacks of abdominal pain for which
no cause can be found. Such cases should be treated as incipient intussusception —
that is to say, avoid puigatives and give digestible foods and small doses of opium.

(6) In various spinal affections the pain is frequently referred to the fbont of
THB ABDOMEN, and among the more obscure causes may be mentioned abdominal
aneurysm pressing on the spine, and cancer or caries of the vertebrae. The first of
these occurs mostly in male adults, the second in the aged, and the third (Pott's
disease) in children. In the latter the child frequently refers to the pain as '" stomach-
ache," worse after running about. The girdle pain of chronic and acute myelitis
should also be borne in mind.

(c) If the patient complain of pain situated chiefly in the lower abdomen,
one might suspect appendicitis {vide supra), cancer or other disorders of the bladder,
peri- and para-metritis (in which there is a good deal of pain shooting down the legs).

254 THE ABDOMEN . [ § 181

extia-utorine pregnancy, pyosalpinz, dysmenorrhoea and all its causes, uterine neu-
ralgia, tubercle or cancer of the prostate or testes, and obturator hernia. Hemor-
rhoids are sometimes attended by pain in the abdomen (which disappears upon the
cure of these), and so also are new growths and various ulcers of tiie lower bowel.
Among the unsuspected causes I have seen pelvic hydatid in a boy of ten. The
fatigue pains of debilitated women may be referred to one or other iliac region.

{d) Pain situated chiefly ik the ttppeb abdomen may bo due to various affec-
tions of the liver, stomach, and spleen. Among the painful affections of the livtr,
perhaps passive congestion, gall-stones and acute cholecystitis, perihepatitis, and
cancer are the commonest ; hydatid is one of the obscure conditions, tiiough it is
rarely painful. Abscess above or below or within the liver should be suspected in
those who have resided in tropical countries. Among the painful affections of the
stomach may bo mentioned gastric (or duodenal) ulcer, gastritis (acute or chronic),
cancer of the stomach — ^which in its most usual form, scir^us of the pylorus, is com-
monly veiy obscure in its early stages — and gastralgia. Painful affections of the
sjdeen are not common, the chief being infarction, but the capsule is sometimes the
seat of a painful inflammation. The enlargement of the organ aids the diagnosis.

§ 181. DifeasM of the Pancreas are fortunately rare, for they are always very obscure,
and are often unrecognisable during the life of the patient.

As far as our present means of investigation go, the Sympknns to which they give
rise are : (1) Abdominal pain, deep-seated in the epigastrium, radiating to the loft
shoulder, and round the left loin ; (2) nausea, and vomiting of glaiiy mucus, anorexia,
and acid eructations ; (3) great debility, rapid emaciation, and mental depression ;
(4) undigested fat and muscle fibre in the faBces ; (5) glycosuria ; (6) frequently jaun-
dice ; (7) a tendency to htemorrhage ; (8) the pancreatic reaction in the urine. Dr.
P. 8. Cammidge ^ has described a reaction in the urine, which he believes to be diag-
nostic of pancreatic disease. Certain crystals are obtained from the urine, which are
said to differ in cases of pancreatitis from those obtained in cases of pancreatic car-
cinoma. (9) When salol is admimstered by the mouth for twenty-four hours, it does
not appear in the urine as carbolic acid. (10) Sahli*s test : the administration of
glutoids of iodoform, hardened in formalin, is not followed by the appearance of
iodoform in the urine. As to Physical Signs, a tumour may be felt only when the
disease is veiy advanced.

The diseases of the pancreas which have been recognised, chiefly after death, are
as follows :

I. HiSMOBBHAOE WITHIN THE Pangbeas, a rare condition, which, if of any extent,
causes death in twenty-four hours, or less (f 171).

II. Pancbeatio Cysts. ^ due to obstruction or obliteration of the duct by biliary
or pancreatic cakub', or cicatricial contraction. An injuiy to the abdomen is the
chief cause. The swelling appears between the stomach and the colon, and does
not move with respiration. Fatty diarrhoea is rare. The fluid withdrawn by. aspira-
tion will emulsify fat, convert starch into sugar, and digest fibrin. The prognosis is
good with suigical treatment.

m. Pancbeatio Calculi are small concretions consisting chiefly of carbonate of
lime. They are visible on X-ray examination, a diagnostic feature which distin-
guishes them from biliaiy calculL

IV. Acute Pancbeatitis is met with in three forms : (1) Acute Hmmorrhagic Pan^
creatitis, which sc^ts in suddenly with agonising pain, and results in death in one to
four days (§ 171). (2) Acute Suppurative Pancreatitis begins suddenly with pain and
iiTogular pyrexia, and may lead to death in three or four hours, but Fitz's cases more
often became chronic, and lasted some months. There may bo several small or ono
large abscess. (3) Gangrenous Pancreatitis, in which necrosis of the organ oocurs, and
it may be passed as a slough by the bowel. Two of Pitz's cases recovered.

^ Bobson and Cammidge, " Diseases of Pancreas,'* 1908.

^ A case of retroperitoneal rupture of a pancreatic cyst occurring in a young man
about twentv-five years of age was admitted in the Paddington Infirmaiy with all the
symptoms of acute peritonitis. Laparotomy was performMl by Sir Freclerick Treves,
but nothing was found until after death, forty-eight hours later. The origin of the
cyst was not even then discovered, but the cellular tissue behind the peritoneum was
infiltrated with the usual pultaceous materiaL

§ 1S2 DISEASES OF THE PANCREAS 255

V. CuRONio PAircREATiTis ^ is a fibiosis of the oigan which mostly runs a latont
course, but has received considerable attention of late yeais because it is frequently
associated with diabetes, especially in those cases where atrophy of the gland ensues.
Tho onset is insidious ; discomfort and distension in the epigastrium is felt after
meals, and drowsiness. Borboiygmi and offensive stools, anemia and emaciation
follow. Paroxysmal pain is complained of above and to the right of the umbilicus,
and tenderness can be elicited there. The pain may be referred to the left scapula.
Lator, by affecting tho bile-duct, it produces jaundice, with dilatation of the gall-
gladdor, and thus resembles gall-stones and cancer of the head of the pancreas.

Tho diagnosis is difficult in early stages, and requires expert analysis of the excreta.
Cammidge*s '* pancreatic reaction " and the presence in the urine of indican, calcium
oxalate crystals, bile, and urobilin, are suggestive of pancreatitis.

Pancreatic Diabetes. — ^The association of glycosuria with pancreatic calculus
was first pointed out by Cowley in 1788. But it was Lancereaux, in 1877, who
maintained there was a special form of diabetes dependent on grave alterations in
tho pancreas (Pancreatic Diabetes), characterised by polyuria, excessive thirst and
appetite, rapid loss of flesh, and glycosuria. Pancreatic diabetes may, however,
occur with lesions of the pancreas other than chronic pancreatitis ; and grave altera-
tions of the organ may exist without diabetes.

VI. Cancer of the Pancreas may be primary or secondary, and is a rare con-
dition. It is said to occur in about 6 per cent, of all cancers (Segro). The symp-
toms are : (1) Pain in the epigastrium, which at first occurs in paroxysms, then
becomes constant, and runs a chronic course. (2) Symptoms of gastric disorder
may be present for months before any other symptom. (3) Jaundice, intense and
persistent from the pressure on the bile-duct, is usually present, and sometimes pain
like biliary colic accompanies this. (4) Tho other symptoms are those above described.
(5) Later on a tumour is found in the epigastrium or in the umbilical region, with
little or no mobility, deep-seated, and hard to define. (6) (Edema of the legs, from
pressure on the inferior vena cava, may occur.

The Diagnosis of cancer and other tumours of the pancreas is always difficult.
A tumour of the liver, pylorus, or transverse colon, is more mobile. Much indican
in the urine points to an intestinal rather than to a pancreatic tumour. No great
stress can be laid on the presence of fat in the faeces, or on glycosuria, but abundant
undigested muscle fibre found in the faeces is more characteristic of pancreatic disease.
Gross's and Sohlecht's tests for trypsin in the faeces assist the diagnosis of advanced
pancreatic disease.

Prognosis. — ^In cancer of the pancreas death usually occurs within four weeks after
the onset of jaundice, or six weeks after ascites sets in. Emaciation and debility
may not come on till late in the disease. The complications are : (i.) Symptoms due
to pressure on the neighbouring organs — intestine, stomach, or portal vein ; (ii.) sudden
haemorrhage into the alimentary tract or the peritoneal cavity ; (iii.) pulmonary
embolism. Sudden death occurs in the last two.

Treatment is mainly symptomatic. Starches and sugars should ]^ limited. Milk
and casein are the most digestible forms of proteid in pancreatic disease. The
administration of pancreatin, pancreon, or similar preparations may aid the diges-
tion. Duodenal catarrh may be allayed by bismuth salicylate ; and urotropin dis*
infects the biliary passages. Opening and draining the gall-bladder has been suc-
cessful in cases of pancreatitis accompanied by jaundice, and other surgical measures
are employed for tJie several diseases of the pancreas.

GENERALISED ABDOMINAL ENLARGEMENT.

§182. Classiflcation. — Generalised abdominal enlargement occurs under
four conditions :

I. Solid abdominal tumours . . . . . . . . . . § 188

II. Gas in the intestines (tympanites), or occasionally in the peritoneum § 183

III. Fluid free in the peritoneum (ascites) . . . . . . • • § 185

IV. Ac3r8tic oolleotion of fluid in the abdomen . . , . . . § 180

^ Cammidge, the Lancet, June 3, 1911.

256 THE ABDOMEN [ § 183

The Routine Frocedurey as previously described (§ 167), should be by
Inspection, Palpation, Percussion, Auscultation, and Mensuration.

It must be remembered that much fat in the abdominal wall or
within the abdomen, enteroptosis, and other causes mentioned under
Fallacies in § 166, may give rise to difficulty in diagnosis of the above
conditions.

If a hard tumour can be felt in any part, turn first to § 188.

If the abdomen is quite soft to palpation and resonant all over, turn
first to § 183.

If the abdomen is dull to percussion in the flanks, and presents the
fluctuation test, turn first to § 185.

If the abdomen is resonant in the flanks and dull in front, turn first to
§186.

The abdomen is uniformly enlarged ; it is soft and yielding to jxUpation ;
and percussion, systenuUicaUy conducted over the whde area, gives a resonant
note. The swelling is probably due to tympanites.

§ 188. Tympanites is the term employed for a flatulent distension of
the stomach and intestines by gas. It should be remembered that flatu-
lent distension may accompany and render obscure a small quantity of
fluid in the peritoneum.

The Causes of tympanitic enlargement are as follows :

I. Atonic and other forms of Dyspepsia are the most frequent causes
of flatulent abdominal distension. It is usually intermittent, and is
generally greatest after meals (§ 204).

II. In Atony op the Colon the bowels are constipated, and the patient
is liable to ** colicky " pains ; but there are few constitutional symptoms

(§ 227).

III. In Tuberculous Peritonitis there is a tendency to the formation
of intestinal adhesions and flatulent distension. In tuberculous peritonitis,
moreover, the distended abdomen has a doughy feel and here and there
a patch of dulness on percussion, which is quite characteristic (§ 176).

IV. " Phantom Tumour " may assume the shape of a generalised more
or less resonant enlargement, but it more often resembles a localised
tumour (§ 188).

V. In Obstruction of the Bowels there is considerable abdominal
distension, accompanied by pain, vomiting, and other general constitu-
tional disturbance (§§ 228 and 229).

Gas in the Peritoneal Cavity gives much the same signs as tympanites, only
there is extreme distension, and hyper-resonance all over to such a degree
that the normal dulness of the liver and spleen is obscured. It is met
with only when perforation of some part of the alimentary canal occurs.
The patient is collapsed, and presents all the symptoms associated with
perforation (§ 1G9). A few hours after the occurrence of the perforation
a delusive liill occurs in the collapse and other symptoms, only to be

§5 184, IW ] FLUID IN THE PERITONEUM ^ASCITES 257

sacceeded by a fatal exacerbation. Perforation of gastric tdcer is the
commonest cause, and one of the diagnostic features of this condition is
the loss of the normal area of liver dulness.

There is uniform abdominal enlargement, which is soft and yielding to
palpation and dull to percussion in parts; the fluctuation sign is
present. There is Fluid wrrnm the Abdomen.

§ 184. When there is Fluid in the Peritoneal cavity, either free or
encjrsted, the belly is soft to palpation, dull to percussion in parts
(either in the flanks or in front), and the measurements show the abdo-
men to be um'formly enlarged.

When the fluid is in any quantity, two special signs can be elicited.
(1) Fluctuation test, — ^When a large amount of fluid is present, a wave
of fluctuation may be seen to travel across the surface when we tap or
" flip " one side. This can only be satisfactorily elicited when the abdo-
men is full and tense. (2) Percussion test, — ^A percussion wave can be
transmitted from one hand to the other through the fluid by the law that
fluids transmit pressure or a blow equally in all directions. Place the left
hand over one side of the dull portion, and tap sharply with the fingers
of the right hand over the opposite side ; an impulse will be felt by the
left hand if fluid be present. In applying the " percussion test " for fluid,
an assistant should place the edge of his hand vertically on the umbilicus.
This will prevent the wave or impulse from travelling across the surface
of the omental and subcutaneous fat instead of through the fluid. Neither
of these signs can be elicited in a gaseous enlargement or a solid tumour.
In obese persons considerable difficulty arises in the detection of fluid.

The fluid may be either (a) free in the peritoneal cavity, when it is termed
ascites ; or (6) enclosed in a cyst, such, for instance, as an ovarian cyst.

(a) If FREE in the peritoneal cavity, it will obey the law of all fluids,
and shijl unth the position of the patient. Thus in ascites (§ 185) when
the patient is on his back you will find both flanks are dull to percussion,
and the umbilical region is resonant; then, if the patient turns on one
side you will find that the uppermost flank which before was dull is now
resonant, while the umbilical region, if there is much fluid, is dull. Much
may be learned from the character of the fluid withdrawn by a trocar.
Ascitic fluid is straw-coloured, with much albumen. HsBmorrhagic fluid
usually means cancer.

(b) If the fluid is encysted — e.gr., ovarian cyst, we can still elicit the
fluctuation and the percussion tests just referred to, but the level of the
dulness will not alter with the position of the patient (§ 186).

There is a generalised uniform enlargement of the abdomen, which gives
all the SIGNS of flxhd, and the fluid alters its level tvith the position of
the patient. The condition is Ascites.

§ 185. Ascites is a term applied to an effusion of non-inflammatory fluid
within the peritoneum (dropsy of the peritoneum). The physical signs of

258 THE ABDOMEN [ § 185

fluid have just now been described above. It is sometimes difficult to
detect a very small quantity of fluid in the peritoneum, but its existence
is rendered probable (i.) by the dulness on percussion of the umbilical
region with the patient on his hands and knees, and (ii.) by finding that
when the patient turns from one side to the other, the flank which was
dull is now resonant.

Ascites may have to be Diagnosed from any of the cystic conditions
mentioned below (§ 186), but certainly the most frequent and important
source of difficulty is ovarian cyst. In ascites (i.) the flanks bulge, (ii.) the
front is flat and resonant, and (iii.) both flanks are dull, but if the patient
turns on his side the upper flank becomes resonant — three features which
are the exact reverse of those found with ovarian and other cystic tumours
(see also table on p. 261). Occasionally peritoneal adhesions (especially
cancerous) may confine the fluid to one part of the abdomen, and then the
fluid does not shift with the position of the patient. A greatly distended
urinary bladder may simulate ascites, but the passage of a catheter readily
excludes this fallacy.

The other Symptoms which accompany ascites belong to two categories :
(1) Those due to pressure within the abdomen — e.g., oedema of the feet
and legs, from pressure on the vena cava and its branches ; later on dilata-
tion of the surface veins of the anterior abdominal wall may occur from
the same cause ; albuminuria from pressure on the renal veins, and dyspnoea
from mechanical impediment in the circulation. (2) There are evidences
of the condition which has caused the ascites, and of all the causes by far
the commonest is alcoholic cirrhosis of the liver. The temperature is
generally normal, except in chronic peritonitis.

The Causes of Ascites are five in number. In reference to the diagnosis
of these causes, if there be any oedema of the ankles, it is important to
ascertain whether this oedema or the ascites came first. For instance,
when Portal Obstruction is in operation, the dropsy of the feet will
have started subsequently to the ascites ; in Heart or Lung disease it
will have preceded the ascites ; whereas in Renal Disease they would
have started about the same time. Ascites with well-marked Jaundice
in an old person is extremely likely to mean Cancer of the Liver or
peritoneum. Ascites with sallowness of the skin in a middle-aged
person is most probably due to Alcoholic Cirrhosis of the liver.

I. Portal Obsfarupiion is the commonest cause of well-marked ascites.
This is recognised in two ways : (a) By a history or presence of the symjh
toms of portal obstruction (of which ascites is only one) ; and (b) the
presence or a history of one of the causes of portal obstruction.

(a) The Symptoms of portal obstruction, in the order in which they
usually appear, are as follows : (1) A liability to attacks of gastric and
intestinal catarrh, as evidenced by pain in the stomach, irritable dyspepsia,
alternating diarrhoea and constipation, and the vomiting of mucus streaked
with blood, especially in the early morning before breakfast. (2) Haemor-
rhoids. (3) Haemorrhage, sometimes in very large quantity, from the

{ IW ] ASCITES 259

stomach and the bowels. (4) Congestion, and therefore enlargement of
the spleen. (5) Asoitbs is one of the later results. (6) Enlargement of
the veins of the abdominal wall from the establishment of a collateral
circulation. (7) (Edema of the legs also appears subsequent to the
ascites, and is due to pressure on the large veins in the abdominal cavity
by the ascitic fluid. (8) Albumen in the urine may arise in the same way,
or from concurrent disease of the kidney ; in the former case the albu-
minuria may disappear after paracentesis.

(6) The Causes of portal obstruction may be grouped into (a) diseases
within the liver, or (0) diseases outside it.

(a) Diseases wkhin the Liver. — Cirrhosis of the liver is by far the com-
monest of all the causes, and this is nearly always due to alcoholism,
there being a history of this and of alcoholic dyspepsia. Simple ascites
without marked jaundice or other obvious symptoms is presumptive of
cirrhosis. Cancer produces portal obstruction usually by the pressure
of the enlarged glands in the fissure, or by masses protruding outside
the liver. Perihepatitis sometimes produces ascites by puckering of the
capsule. Ascites only very rarely accompanies hepatic cangestiotiy and
never fatty liver, hydatid, or abscess.

iP) The causes of portal obstruction outside the liver are : (1) Cancer of
the stomach, duodenum, or pancreas, and various other tumours pressing
on the vein. (2) Enlargement of the glands in the fissure of the liver
(cancerous, tuberculous, or syphilitic). (3) Thrombosis of the portal vein
is rare, and the symptoms are very acute.

II. In Heart Disease^ either primary {e,g,, mitral disease and cardiac
dilatation) or secondary to lung mischief, the ascites is generally part
of the dropsy aSecting the cellular tissues and other serous cavitius of
the body. Here dropsy of the feet wiU have preceded the abdominal dropsy ^
and there will be a previous history of palpitation, dyspaoea, and perhaps
cough. An examination of the heart will also reveal the nature of the
disease.

III. In Kidney Diseaie ascites may be part of a General Dropsy affect-
ing the face, limbs, peritoneum, pleurae, and pericardium. The fact that
the dropsy started in all of these situations about the same time reveals
this cause. Albuminuria is frequently enough a consequence of the
pressure of the ascitic fluid, but the presence of epithelial casts almost
certainly indicates that the real disease was primary. It usually takes
the form of acute or chronic parenchymatous nephritis, rarely waxy or
granular kidney.

lY. Chroiiic Peritonitis is another cause of fluid in the peritoneum. An
idiopathic form oi chronic peritonitis is sometimes described, but it is
practically never met with apart from a deposit of tubercle (in the young)
or of cancer (in the aged), § 176. In the tuberculous form adhesions
rather than fluid are met with ; in the cancerous it is vice versa.

y. A small amount of eSusion into the peritoneum is found in severe
unffifwlft and some other blood disorders ; but it is never very great.

260 THE ABDOMEN [ { IM

VI. Chylous ascites, or the collection of chyle in the peritoneal
cavity, occurs as the result of obstruction of the thoracic duct, or
it may occur after trauma, or in spleno-medullary leukaemia. In
tropical countries it is more often due to the adult Filaria sanguinis
hominis.

The Prognosis and Treatment of Ascites are very largely those of the morbid
condition with which it is causally related. The Prognosis of Ascites due
to portal obstruction depends very much on the nature of the intra- or extra-
hepatic lesion which has produced it, as given above and in Chapter XII.
The degree of the obstruction is measured by the amoimt of ascites and
other sjTiiptoms present, 'and still better by the amount and frequency
of the haemorrhage that has taken place from the stomach or intestines.
Life may be prolonged for many years even when a considerable amount
of ascites has accrued, provided it has come on slowly, and time has thus
been afEorded for the gradual establishment of the collateral circulation
through the surface veins of the abdomen and other collateral channels.
It is in this sense that repeated tappings are good, for in this way time
is gained for the establishment of collateral circulation. In cases of
alcoholic cirrhosis the habit must be abandoned, otherwise the patient
cannot live longer than six to twelve months, for ascites indicates an
advanced condition of cirrhosis ; in cases treated early, recovery may be
complete.

The Treatment of Ascites, like its prognosis, must depend upon its cause
iq.v.). The treatment of ascites due to portal chstructiony and to some
extent that of other forms, is as follows : (1) Hydragogue purgatives are
certainly called for, and mag. sulph. and the other salines are the best.
Elaterium seems particularly valuable if given in sufficient quantities to
produce three or four watery stools a day. (2) Diuretics are recom-
mended by some, but in my experience there is no form of dropsy in
which they are of so little use as in ascites, at any rate imtil the pressure
has been relieved by tapping. Diuretin, copaiba resin, and cubebs are
useful, and I have given pil. digitalis co. with some benefit after repeated
tapping. (3) Tonics are useful combined with the preceding, such as a
mixture containing pot. bitar., fer. tart., and digitalis. (4) Paracentesis
is generally called for sooner or later. Some physicians say it should be
put ofE until it is called for by the urgency of dyspnoea. In cancer this
is certainly a good rule, but in cirrhosis of the liver it is best to operate
at once in all cases where there is much fluid, unrelieved by medicine.
It is often found that medicines which were useless before are efficacious
after the operation, because the kidneys are relieved from pressure.
Sometimes complete recovery takes place after repeated paracentesis,
because time is thus afEorded for the establishment of the collateral cir-
culation as above mentioned. It is best to use a small trocar with the
tube conducted to a pail, so that the peritoneum may gradually empty
itself. With a large one leakage may remain, or peritonitis may ensue.
In 1896 the Talma-Morison surgical method of promoting the collateral

§186]

OVARIAN CYST

201

circulation by the artificial production of omental adhesions in cases of
alcoholic cirrhosis was introduced, and has been attended by a measure
of success.

There is a generalised abdominal enlargement which gives aU the siqns
OF FLUID (§ 184) ; but the fluid does not alter its level toith the jxmtion
of the 'patient. There is Encysted Fluid (probably ovarian) in the
Abdomen.

By far the commonest of such cystic tumours is an ovarian cyst.
Other and less common cystic abdominal tumours are hydramnios, cystic
FIBROMA of the uterus, hydro- and pyo-nephrosis, pancreatic cyst,
a large hydatid, a cyst of the gall-bladder, and an encysted ascftes.

§ 186. I. Ovarian Gyst^ is centrally situated, and grows from below
upwards. The enlargement is fairly uniform, and it gives all the signs of
fluid (§ 184). But the level does not alter with the position of the patient ;
and whereas the umbilical region is dull qu percussion, the flanks are
resonant. On palpation it is tense and elastic, and in malignant ovarian
cysts nodules can be felt in the walls. The diagnostic features between
ascites and ovarian cysts are given in Table XIV.

Table XIV.

Itupeetion,
Percusiion,

MeaturemetU..

AtcUet,

Flanks bulge, front flat.

Ovarian Cyst,

Flanks flat, front bulges.

Flanks dull, front resonant. ; Flanks resonant, front dull.
On turning, upper flank becomes No alteration of dulness on turning,
resonant.

UmbUicns to xiphoid greater than' Umbilicus to xiphoid less than um

umbilicus to pubes.
Circumference at umbilicus greater

than slightly below.
Navel to iliac spine same both sides.

bilious to pubes.
Circumference at umbilicus less than

slightly below.
Navel to iliac spine greater one side
than another.

The features associated with it are (1) a history of it having grown up-
wards from the pelvis, and (2) these tumours (unlike encysted ascites) may
be of very rapid growth, and reach quite a large size in three or four months.
(3) There have usually been menstrual irregularities, though by no means
always. There may have been no general symptoms of any kind, but
generally some pain and local discomfort have been complained of. Often
when the cyst contains pus there is little or no fever. When there is a
history of attacks of pain, it generally indicates adhesions, an important
matter from an operator's point of view. An examination of the uterus
usually reveals nothing. A malignant cystic ovarian growth is indicated
by (1) the presence of nodules in the walls ; and (2) the age of the patient
and a history of emaciation, and severe pain.

* Parovarian cysts are rare. They present much the same symptoms as ovarian cysts.

262 THE ABDOMEN t § IW

Diagnosis, — In the earlier stages the diagnosis of an ovarian tumour is
sometimes difficult. It is an elastic, movable, and globular swelling ; the
uterus is not enlarged, and it can be defined as quite separate from the
tumour. In this stage it may have to be diagnosed from h^fdro- or fyo-
salpinx. Para- and jieri-metric exudation and pelvic hcematocde would be
very firmly fixed in the pelvic cavity and accompanied by constitutional
symptoms. In extra-uterine foetation there would be morning sickness,
a patulous os uteri, and other symptoms of pregnancy, with an empty
uterus.

In the later stages ovarian cysts have to be diagnosed from all the con-
ditions mentioned below.

II. Prsqnakcy with htdbamnios and a thin uterino wall is sometimes very
difficult to diagnose from an ovarian cyst, for both develop very rapidly. Experi-
enced clinicians have been known to fail in the differentiation. The symptoms of
pregnancy (see § 328), the exactly central position of the tumour, and the softened
cervix, may aid us in the diagnosis. Hydatid mole presents similar difficulties, but it
is fortunately more rare.

IIL Laboe cystic fibroid of the uterus, especially of the subperitoneal variety,
may produce the signs of a fluid tumour. It is recognised by (1) its connection with
the uterus, which is enlarged ; and (2) its slow grow&, which may extend over many
years ; and (3) monorrhagia in some cases.

IV. A LABGE hydatid CYST of the spleen or liver, a hydro- or pyo-kefhrosis,
a dilated oall-bladdeb, a large pancreatic, omental, or mesenteric cyst, or a
large perityfhlitio abscess, may on rare occasions produce the appearance of a
general fluid enlargement of the abdomen, and may require to be diagnosed from
ovarian cyst ; but they are nearly always asymmetrical. They grow from, and their
peroussion dulness is continuous with, the organs whence they rise ; they are rofened
to among Abdominal Tumours (§ 187).

V. Encysted ascites is not common. It may result from previous peritonitis,
of which there will probably be a history. Mora frequently, perhaps, it results from
tuberele or cancer of the peritoneum (§ 176). In very rare cases congenital deficiency
or adhesions may exist. In all of these there is a want of symmetry in the onlai^ge-
ment and in the fluid, an absence of the associated symptoms of ovarian tumour,
and a history or other evidences of the cause in operation.

The Prognosis of ovarian tumour is always serious, though in the non-
malignant form it may be quiescent for some years. If not treated, a
cyst may go on (1) to rupture and fatal peritonitis ; (2) it may become
inflamed ; (3) the pedicle may become twisted ; (4) haemorrhage may take
place into its cavity.

The Treatment is entirely surgical. The earlier the cyst is removed
the better. It is best to do this before the occurrence of attacks of
pain indicating inflammatory adhesions. Tapping is a temporary
measure only; it certainly increases the risks for future operation, and
is justifiable only in elderly patients where operation is for some reason
impossible.

ABDOMINAL TUMOURS.

§ 187. Method of Proeednre. — ^We now turn to the second group of
abdominal enlargements — ^namely, those in which the enlargement has
originated in, or is localised to, one part — i.e., Abdominal Tumours. It
is only by repeated and careful examination that mistakes can be avoided

iW] A BDOMINAL TVMoVM—PALLAOlEa 26^

in the diagnosis of abdominal tumours. The same methods are adopted
here as in general enlargement (§ 167), which should be consulted. (1) /n-
spection in the recumbent, and sometimes in the erect, posture should never
be omitted; (2) Palpation, with a flat hand previously warmed and with
the patient's abdominal muscles thoroughly relaxed by a suitable posture ;
(3) Percussion, to define the boundaries and nature of the tumour, and
its continuity with some organ ; (4) careful Measurement made and
recorded both for the comparison of one part with another, and to note
the progress made by the growth; and (5) Auscultation, which is especi-
ally useful in the diagnosis of late pregnancy.

Fallacies of Abdominal Tumours, — (1) Obesity may oSer a serious
obstacle to the examination of abdominal enlargements or tumours. In
these cases the umbilicus is usually depressed. The only way to arrive
approximately at a correct decision is to place the hand flat upon the
belly and then dip the fingers suddenly and forcibly inwards.

(2) The presence of f,uid within the abdomen, together with a solid
tumour, may prevent our discovering or examining the latter thoroughly.
The difficulty may be obviated to some extent by suddenly flexing the
fingers as in the case of obesity.

(3) FcBoal accumulations may simulate malignant and other tumours,
though they can generally be indented by the fingers. They are always
situated in some part of the large bowel. In doubtful circumstances a
course of castor oil or other hydragogue purgative is desirable. But they
may exist "for many weeks in spite of purgatives.

(4) A ^' "phantom tumour " is a swelling (usually tympanitic, sometimes
dull), produced by irregular muscular contraction, and it is wonderful
how precisely it may simulate a solid tumour. It is apt to appear and
disappear suddenly, hence the name. The condition is met with for the
most part in young hysterical women, and is usually beyond the control
of the patient. It is a frequent cause of error in diagnosis. It is generally
due to spasmodic contraction of one or both recti muscles. Spasm of
the diaphragm may produce a generalised abdominal enlargement by
pushing the viscera down. The patient should be placed in a position
of perfect ease for the relaxation of all the muscles of the body, with the
knees drawn up and the neck slightly bent. Sometimes nothing but tho
administration of an ansBsthetic to complete narcosis will enable us to
establish the diagnosis, and this must be done in cases of importance.

(5) The liver occasionally presents the abnormality of an extra lobe.
Displaced or movable organs may be mistaken for tumours. (See § 166.)

Having excluded these fallacies, and being satisfied as to the existence
of an abdominal tumour, there are five points to which our attention
should be directed :

1. The first and most important question is the locality of the tumour^
what region is it situated in, or where did it start ?

2. To ascertain with which organ it is connected, consider what organs
are located in the region occupied by the tumour, and then see if

264 THE ABDOMEN [ § 188

it be structurally continuous by palpation and percussion with one of
these.

3. If it moves wUh the breathing of the patient we know that it must
be connected with the diaphragm, or some organ depressed by it during
respiration, such as the spleen, liver, stomach, intestines, or omentum.
If fixed, it is a tumour of the kidney (imless it be dislocated), aorta,
lymphatic glands, or some other organ unaffected by respiration, or
bound down by adhesions.

4. Inquire for a history of any disease or functional disturbance of the
abdominal organs — e.g., in the case of the kidney, whether the urine con-
tains, or has contained, blood or pus — although the tumour may appear
to be far from these organs ; or perhaps there has been jaundice pointing
to hepatic mischief.

5. The diagnosis of the nature of the tumour depends very largely upon
its history and the age and sex of the patient. Tense cystic tumours are
extremely difficult to differentiate from solid growths, but we can try to
obtain the percussion and fluctuation tests (§ 184). There is also anothei
question which very frequently presents itself for consideration — ^viz., is
the tumour benign or malignant ? The general symptoms of malignant
disease (cancer) are discussed in § 415 ; but the age of the patient, and
the rapid course and lethal tendencies of the disease, are the chief means
of differentiating it.

§ 188. If there is a visible or palpable tumour in the abdomen^ ascertain
which REGION the tumour chiefly occupies or originated in, and refer to
that region in the following summary. Having identified its origin in this
way, reference must be made to the diseases of the organ affected to ascertain
the NATURE of the tumour,

I. Right Hypoohondrium. — The conmionest tumours in this position

are tumours of the liver, especially cancer and enlargement of the organ.

The features which hepatic tumours present in common, in addition to

their position, are : (1) They are not covered in front by resonant bowel,

and their dulness is continuous with that of the liver ; (2) they move with

respiration; and (3) there are ascites, jaundice, and other evidences of

liver derangement. It must not be forgotten that hepatic tumours may

be simulated when the liver is pushed down by emphysema, or by pleuritic

and pericardial effusions ; or that it may be puckered by contraction of

the capsule, and so simulate a tumour or enlargement (Diagnosis of

Hepatic Enlargements, § 235) ; Riedel's lobe (see below) is another fallacy.

Dilatation of the gall-bladder (e,g,, by gall-stones) is recognisable as a

tense rounded swelling below the ninth costal cartilage. There is only

occasionally a history of biliary colic but always a history of "chills"

(biliary fever), see § 241. Tumours in this region may also be connected

with the duodenum or right kidney (see II. and IV.).

Ritdd's Lobe (lingiform or floating lobe of the liver). — In certain cases, usually
associated with gall-stones retained within the gall-bladder, a tongue-shaped process
projects downwards from the right lobe of the liyer, or the lobus quadratus. It may

5188] ABDOMINAL TUMOURS 265

raaoh as far as the iliac crest, or even to the iliao fossa. In hardly any of the oases
in which it has been observed (Gl^nard^ collected eighty), has the condition been
correctly diagnosed until operation or an autopsy was performed. It has most often
been mistaken for floating kidney, and has also been taken for distended gall-bladder,
hydatid cyst, new growth, and omental tumour. It is sometimes tonder, its shape
more or less that of a pear. Under chloroform its connection with the liver might
possibly be made out.

Suprarenal Tumours become manifest in the right or loft hypochondrium, and are
difficult to distinguish from tumours of the liver, gall-bladder, and spleen respectively.
Mayo Robson summarises the symptoms thus : (L) Pain radiating from the tumour
across the abdomen and to the back ; (ii.) pain complained of at the shoulder tip ;
(iu.) emaciation, with nervous depression, and digestive disturbance ; (iv.) a tumour
felt beneath the costal margin (right or left), at first movable with respiration, but
soon fixed ; and it can bo felt posteriorly in the costo- vertebral angle ; (v.) absence
of urinary and gall-bladder symptoms. More recently other symptoms have been
doscribed in relation to suprarenal tumours. In children precocious general and
sexual development may occur, ^ or precocious obesity and hirsutes.^ When the
tumour is sarcomatous, there is a special tendency to secondary affection of the bonos»
particularly those of the skuU,^ and to exophthalmos, which may occur befoie any
abdominal tumour can be felt. Dr. R. S. Frew* finds a different syndrome of symp-
toms according to whether the primary sarcomatous growth affects the right or the
kft suprarenall When the left is involved, exophthalmos appears first on the left
side, and pain in the limbs is common.

II. In the Epigastric Region tumours may be comiected with the

liver (vide supra) ; but the first tumour which would occur to one's mind

would be Cancbr of the Stomach — t.e., a hard irregular swelling attended

by vomiting, " coffee-ground " in character. The commonest form of

malignant disease of the stomach, however, is scirrhus of the pylorus, in

which condition copious vomiting at long intervals and other gastric

symptoms appear long before any swelling can be detected (§ 208).

Tumours of the duodenum may sometimes be distinguished from those of

the stomach by their immobility during a deep respiration.

Pancreatic cysts may cause a fluctuating swelling in the epigastrium, but their
detection is extremely difficult. There may bo a histoiy of pain, and symptoms
of pancreatic disease (soe § 181). Cysts of the small omental sac present a similar
swelling. Pulsation in the epigastrium is a symptom of that frequent condition,
dilated right ventricle, and it must not be mistaken for abdominal aneurysm (vide
infra).

III. In the Left Hypochondrium tumours of the spleen originate,
and sometimes they attain to an enormous size. These are fxilly discussed
in § 260. They move with respiration, and they make their way forward
m front of the colon. The tumour can generally be moved forwards by
getting the hand behind it, a procedure which distinguishes them from
tumours of the left kidney, and they present the characteristic splenic
notch (§ 260). They resemble tumours of the left lobe of the liver, but
these latter cannot be displaced downwards by the hand. Other tumours
in this position may be connected with the stomach, fancreas, liver, kidney,
and sigmoid flexure.

1 " Les Ptoses Viso^rales," Paris, 1899.

2 Bulloch and Sequeira. Trans. Path. Soc., April, 1905.

3 Guthrie, Trans. Clin. Soc., 1907. vol. xl., p. 175.

* Hutchison, Quarterly Journal of Medicine, 1907, vol. i.. No. 1.

* Frew, (quarterly Journal oj Medicine, January, 1911.

266 TBE ABWMEN [ { 188

IV. The Lumbar Region may be the starting place for Renal Tumours,
which are characterised by four features : (i.) Their fixity during respira-
tion, (ii.) Dulness in one flank, and, unless both kidneys are involved,
resonance in the other, (iii.) They are always resonant in front, because
as they make their way forward they push the colon in front of them ;
and (iv.) there is no resonant part between the dulness of a renal tumour
and the spine, as there would be in the case of a splenic tumour. In many
the rounded and reniform shape of the kidney is retained. They are
distinguished from hepatic tumours by the dulness in the flank not being
continuous with that of the liver, and by the presence or history of blood,
pus, or other urinary changes. The commoner forms of renal tumours
are hydro- and pyo-nephrosis, renal sarcoma (commonest tumour in
children), and perinephric abscess. Pyo- or Hydro-nephrosis are cystic
tumours, containing urine tiM or without pus respectively (see § 315).
Hydro-nephrosis may be almost painless, not tender, and tmattended by
any subjective or constitutional symptoms; pyo-nephrosis is always tender,
and attended by hectic fever and malaise. Hydatid of the kidney may
only be evidenced by swelling ; sometimes it gives a thrill on percussion.
Other tumours starting in the lumbar regions may be connected with the
ascending and descending colon.

Movable Kidney is one of the most frequent of abdominal tumours.
It may be found in any part of the cavity below the liver. Its mobility,
rounded or reniform shape are characteristic, but not always easily
detected. There is a characteristic pain of a dull, aching, or dragging
character in the back, increased by exertion (see § 177).

V. The Left Iliac Region may be the seat of a tumour caused by
Cancer of the Sigmoid Flexure, and this is the most frequent position
in the bowel for cancerous growth. Cancer and other tumours of the large
intestines are distinguished generally by their free mobility (unless fixed
by adhesions). They are, when cancerous (far the commonest neoplasm
of the intestines), attended by irregularity of the bowels, generally chronic
diarrhoea. The commonest starting-point for primary cancer of the bowel
is, as just mentioned, the sigmoid flexure ; but before a cancerous swelling
can be detected in the left iliac region the patient will have been troubled
with recurrent diarrhoea and pain, sometimes melsena. These symptoms
are followed in course of time by oedema of the leg or sciatica. In cancer
of the peritoneum all the intestines may become matted together, and
although fluctuation may be detected, there is little or no fluid in the
peritoneal cavity. Sarcoma of the smaU intestines gives rise to hard,
irregular, nodular, usually multiple tumours, and, in addition to the signs
just mentioned, there are the advanced age of the patient and cachexia.
Constipation, going on sometimes to obstruction, may also be present.
The prognosis of cancer is given in Chapter XVT. But so-called " colloid
cancer" of the peritoneum is a remarkable exception in regard to its
duration, and it may go on for years before death occurs. The treatment,
which is not very hopeful, is referred to under " Emaciation."

J 18S 1 ABDOMINAL TUMOURS 267

VI. The Right Iuao Region is the position ia which Appendioitis is
usually manifested ; it is fully described under " Abdominal Pain " (§ 175).
Intussusception of the bowel, which occurs mostly in childhood, gives rise
to a soft, sausage-shaped swelling generally situated in this region (§ 228).
Pdvic cdlulitis may form a firm swelling in either iliac region. Its othet
features are (i.) vaginal examination reveals a tender swelling in the corre-
sponding fornix, pushing the uterus to the opposite side ; (ii.) there is a
history of acute pain and fever at the onset of the condition, frequently
following childbirth or abortion. Cancer of the ccBcum,^ contrary to what
we might expect, often constitutes a movable tumour in the iliac region,
and is very apt to be mistaken for masses of feeces. Cancer of the csecum
may be attended by suppuration, so giving rise to abscess in this region
with pyrexia. The history of such cases may nm a long course, and,
except in the age of the patient, resemble chronic appendicitis. Psoas
abscess may point in this region.

Vn. The Umbilical Region is the starting place of tumours connected
with the pancreas, duodenum, mesenteric glands, and aorta, all of which
are immobile during respiration ; though a tumour in this position is far
more often connected with the stomach, liver, or large bowel, which move
with respiration. Enlargement of the mesenteric glands may be sometimes
detected in spare subjects by grasping the two sides of the abdomen either
between the two hands or the finger and thumb of one hand. When large
enough to form a tumour, they are fixed and matted together.

Aneurysm of the Abdominal Aorta is a pulsatile and expansile swelling also im-
mobile during respiration. In thin subjects a thrill may be felt, and a murmur
heard. In auscultating the abdominal aorta we must be careful not to produce a
murmur by pressure of the stethoscope. It is attended alwajrs by a severe fixed
neuralgic pain in the spine, and sooner or later breathlessness and cardiac signs. It
is these latter symptoms which distinguish true aneurysm from " pulsatile aorta '*
(see below), and from a swelling in front of the vessel to which the pulsation has
been communicated. An endeavour should be made to grasp the swelling on each
side, so as to observe the expansile naturo of the tumour.

PvUating Abdominal ^orto '(throbbing in the belly).— Dyspeptic subjects and
nervous females are often troubled with marked pulsation of the abdominal aorta,
which is sometimes obvious both to the patient and the doctor. There is in this
affection great local discomfort, and even pain, with marked pulsation, obvious to
both inspection and palpation. The diagnosis from aneurysm rests partly on the
fact that the pulsation is not limited to any part of the aorta, and partly that such
rapid and violent action of the heart is not common in aneurysm.

VIII. The Hypoqastbio Region is the situation whence Bladder,
Utbeinb, and Ovarian and Tubal Tumours grow. Ovarian tumours
(which are nearly always cystic) are usually characterised in the early
stages by their free mobility, unless they are malignant, and their rapid
growth (§ 186). Tumours of the bladder are usually rendered sufficiently
obvious by changes in the urine. Tumours of the uterus are similarly
revealed by uterine symptoms, excepting perhaps some subperitoneal
fibroids. These may reach a large size without any sjrmptoms at all;
their origin and relations are readily detected by bimanual examination.

^ Clin. Soc. Trans., November 24, 1899.

268 THE ABDOMEN [ § lU

Pregnancy causes a symmetrical enlargement, starting from the hypo-
gastric region about the third month of gestation (§ 328). Among the
rarer tumours in this region pelvic hydatid and pelvic haematoccle may
be mentioned.

The Nature, Prognosis, and Treatment of these various abdominal
timiours are discussed imder the organ with which they are connected.

§ 189. Flattening or Recession o! <he Abdcmcn is i cU sign of any great
importance. " Ventre plat, enfant il y a," is a French expression signify-
ing that the abdominal wall slightly recedes during the first two or three
months of pregnancy. It is met with in abstinence from food, and in
wasting disorders, such as cancer and tubercle. It may be present also
in intestinal, hepatic, and renal colic, and it may occur as a consequence
of excessive purging or vomiting. A hollow or " boat-shaped " abdomen
is said to be characteristic of meningitis in infants. It may also occur
when acute general peritonitis is present, especially in children.

CHAPTER X

THE STOMACH

Two features cannot fail to strike the student in this department of
medicine. The first is that we are very largely dependent upon sub-
jective symptoms in the investigation of disorders of the stomach, a large
proportion of the disorders of this organ being functional. Until the use
of the ** test-meal " (§ 199), and methods for estimating the motor-power
of the stomach (§ 198), were adopted, we had to rely almost entirely upon
the patient's sensations before and after meals to know how the stomach
had been discharging its functions. The other feature relates to the
important and widespread efEects which derangements of the stomach
produce in the general economy. The nutrition, of course, fails; but,
apart from this, sufferers from gastric disorders are always liable to
mental depression, which may sometimes be extreme. Prostration is
apt to occur in all acute abdominal diseases ; but in chronic disorders
of the stomach the functions of the nervous system may be so profoundly
disturbed by neurasthenic and other symptoms that the physician may
overlook the primary cause of the mischief — namely, malassimilation of
food.

PART A. SYMPTOMATOLOGY.

The symptoms which reveal disorders of the stomach may be local
(viz., epigastric pain or discomfort, nausea or vomiting, hsematemesis,
dryness or bad taste in the mouth, flatulence, heartburn, water-brash,
thirst, altered appetite) ; or general and remote (viz., cardiac symptoms,
various nervous derangements, skin symptoms, and emaciation).

Among the Local Symptoms of gastric disorder, pain or discomfort
AFTER FOOD, and NAUSEA or VOMITING, are perhaps the most constant
and important — t.e., the cardinal symptoms. H^matemesis is less fre-
quent, but more serious. The other local symptoms are also of much
value for diagnostic purposes.

§ 190. Gastric Pain, or discomfort, in diseases of the stomach, is a most
important local feature. Although it is not in every case sufficiently
constant in its characters to enable us to establish the diagnosis, never-
theless it merits the closest study. In some cases it is altogether absent
(even when simple ulcer or malignant disease exists), but when present,

269

270 THE STOMACH [ % 191

the features which should be noted are its j)osition, its character^ its degree^
its constancy y and above all, its relation to the taking of food.

Its Position is usually over the epigastrium, but pain is very frequently
complained of between the shoulders, and very severe pain in the back
may also occur. A very localised pain with tenderness is characteristic
of ulceration. In ita character it varies considerably. Sometimes it is
like a dull weight or a feeling of distension, such as occurs in atonic
dyspepsia and chronic gastritis; or it may be of a burning character,
and such is the pain of acid dyspepsia ; or it may resemble abdominal
cramp, as in spasm of the pylorus, or in some cases of gastralgia. Sharp
or lancinating pain of a continuous character usually attends ulcer or
cancer of the stomach.

Its Relation to Food is by far the most important feature of the pain
in gastric diseases : (a) It comes on at once and lasts a variable time in
atonic dyspepsia, in acute gastritis and in ulcer (simple or malignant).
In simple ulcer the pain is at once relieved by vomiting — a very charac-
teristic feature. (6) When pain comes on an hour or more after food^ it is
due to excessive acidity, either from hypersecretion or fermentation
(organic acids). In hypersecretion, pain is relieved by taking food, but
not in fermentation, (c) Pain coming on without time rdaiion to food is
characteristic of gastralgia. If pressure over the seat of fain relieves it,
the condition is probably functional, not organic.

Fallacies, — Pain of the acute type met with in gastralgia may be mis-
taken for biliary cclio, but in that condition the pain is greater on the
right side, and is sometimes followed by jaundice. In hepatic disorders,
pain is more often limited to the right hypochondrium. The spine should
always be examined for caries, especially when stomach pain is complained
of by children. The pain in such cases is referred to the terminations of
the intercostal nerves. The gastric crises of tabes dorsalis may be mis-
taken for simple gastritis. Pain in the chest (§ 23) must not be mistaken
for stomach pain. True angina 'pectoris might be mistaken for that type
of dyspepsia where the stomach is distended with gas and hampers the
heart's action. Darting or lancinating pain may be due to growths in-
volving the nerves near the stomach. In acute pancreatitis there is
extreme pain of sudden onset in the left hypochondrium, and the case
usually terminates fatally in a few days. Other pancreatic diseases are
also attended by pain in the situation of the stomach.

§ 191. Nausea or Vomiting is, after pain, the most frequent and most
definite symptom of stomach disorders, though it arises, also, in many
other conditions. Its causes may be grouped under three headings :
(a) Local Causes ; (b) Nervous Causes ; and (c) Toxic Causes. Water-
brash (vide infra) is sometimes spoken of by the laity as " vomiting," but
is not true vomiting. Regurgitation from a dilated oesophagus is another
fallacy.! The mechanical discomfort of prolonged coughing may induce

^ How closely regurgitation from the oesophagus, especially when it is dilated, may
simulate vomit from the stomach is evidenced by three cases narrated by Dr. J. S.

{ 191 ] CA USES OF VOMITING 271

vomiting. Phthisical patients may come complaining only of the vomit-
ing, and the physician may be led in consequence to treat the stomach
instead of the lungs.

(a) Local Causes, producing vomiting, include : (1) Errors of diet, such
as shell-fish, tinned food, excess of alcoholic and other irritating foods.
Under these circumstances the vpmiting of the peccant material occurs
soon after ingestion. (2) Irritant and corrosive poisons and emetics also
speedily give rise to vomiting. The diagnosis of this cause is aided by
(i.) an examination of the vomit, which should alioays he preserved; it
may smell of phosphorus (which is luminous in the dark), or of carbolic,
or other acids, (ii.) An examination of the mouth for any corrosive
action, (iii.) The occurrence later of the toxic effects peculiar to the
several poisons ; and (iv.) a history of poisoning obtained from the patient
or his friends. (3) Fermentation of the contents of the stomach, such as
that met with in dilatation, when the vomiting may occur at very con-
siderable intervals, sometimes of a day or two ; the vomited matter also
is frothy, and contains sarcinsB and yeast (Fig. 61, p. 282). (4) Diseases
such as acute gastritis, cancer, and simple ulcer are usually accompanied
by vomiting. In chronic gastritis the vomiting is of mucus, and occurs
in the early morning.

(5) Persistent vomiting and marasmus in young infants are the two chief symp-
toms of Congenital Hypertrophic Stenotif. The symptoms begin about the end of
the second week of life — (L) forcible vomiting, which cannot be stopped ; (ii.) progres-
sive emaciation ; (iii) constipation; and later (iv.) visible peristalsis of the stomach,
(v.) A small hard nodule (the hyportropbied pylorus) may be made out under the
upper part of the right rectus. Careful feeding and lavage will sometimes e£feot a
cure, and operation (pyloroplasty, Loreta's operation, gastro-entorostomy) has been
successful, but the mortality is very high.

{b) VoMrrmo or Nervous Origin may be classified under two groups —
(a) that due to cerebro-spinal irritation, and {/3) that due to visceral and
sympathetic irritation.

(a) That due to Cerebro-spinal iRRnAXiON. 1. In Hysterical Vomiting
the vomiting may follow any or every kind of food, no matter what its
quantity or quality may be ; or perhaps digestible articles like milk will
cause vomiting, while indigestible things like cheese may be retained.
Sometimes this vomiting resembles a simple regurgitation, as compared with
the urgent vomiting of organic disease, the symptoms of which are wanting.

2. In Migraine and Bilious Headache the patient perhaps awakens
with a headache, and vomits only bile (merely an indication that the
vomiting is urgent, or that the stomach is empty) ; the headache being
relieved hy the sickness (§ 605).

3. Another important cause of vomiting is Cerebral Disease — e.^.,
tumour, early meningitis, abscess, M6ni^re'8 disease. This is recognised

Bristowe (" Clin. Lects. and Essays on Dis. of the Nervous Syst./* pp. 42 ei seq.). The
chief differential features are the ease and promptness with which food is returned
from the oesophagus in cases of dilatation and spasm, the absence of an acid reaction
in the matters so returned, and the absence of signs or symptoms definitely referable
to the stomach.

272 THE STOMACH [ f 191

by : (i.) The vomiting occurs without relation to food ; (ii.) there is no
nausea ; (iii.) the vomiting may be excited by simple change of posture ;
(iv.) the presence of other cerebral s3nnptoms, such as vertigo and perhaps
optic neuritis (Chapter XIX.). Vomiting may also attend the gastric
" crises " of locomotor ataxy. It occurs at intervals, and is usually severe.
It is recognised by the absence of the knee-jerk and the presence of other
symptoms of the disease.

{P) Reflex vomiting due to Sympathetic or Visceral Irritation may
be met with in a great many abdominal disorders, such as peritonitis,
pancreatitis, intestinal, biliary, or renal colic ; in all stages of intestinal
obstruction, in strangulated hernia, and with intestinal new growths. In
the last named the attention of the physician is often drawn from the true
source of trouble. It occurs also with pregnancy, uterine and ovarian
disorders. If at the end of an operation the surgeon puts in stitches while
the patient is coming out of the anaesthetic, vomiting is at once excited
every time the needle is put in ; this is especially noticeable with children.
Pharyngeal irritation, especially in alcoholics and smokers, leads to pro-
longed hawking often succeeded by vomiting.

(c) Toxic Causes are uraemia, Bright's disease, and jaundice. Some
of the acute specific fevers are accompanied by vomiting, especially at
their advent. The vomiting of Addison's disease, hyperthyroidism, and
pernicious anaemia comes under this heading. After anaesthetics vomiting
may be urgent ; sometimes this is due to blood in the stomach, and will
cease when it is expelled.

The Treatment of vomiting must be directed to its cause, but there are
certain measures which can be applied to relieve the symptom. The
patient should be kept absolutely at rest in the horizontal position, and
without food, or only given milk in small quantities at a time, and iced
water. Milk diluted with barley-water, whey, or peptonised milk are
given where ordinary milk is not retained. Among the remedies which
may be employed are effervescing mixtures, alkaliesh, ydrocyanic acid,
bismuth, drop doses of vinum ipecacuanha or Tr. Iodine, opium, and
acetanilid (especially in the vomiting after anaesthetics). Sod. Bicarb, oi.
to Oi. water, seidlitz powder (if the vomiting be due to constipation) or
calomel. Bromides and hydrocyanic acid are useful for nervous vomit-
ing ; a mustard-leaf applied to the epigastrium may also be useful. For
Sea-sichnesSy chlorobrom, bromides, morphia, and recently chloretone and
validol are recommended very highly.

Cyclical or Recurrent Vomitiiig is an occasional condition occurring in
children. Usually two or three attacks occur in the course of a year;
they last a few days to two weeks, and come on without assignable cause,
even with the most careful dieting. An attack comes on suddenly with
drowsiness, constipation, and perhaps pyrexia ; all food is vomited ; the
breath smells sweet from the presence of acetone, and acetone and diacetic
acid are found in the urine (vide § 287). Drowsiness and restlessness
increase, and cases have been mistaken for meningitis and intestinal

§ 198 ] OA USES OF HJBMATEMESlJ^ 273

obatruotion. The condition is probably toxsemic in origin. It is im-
portant to open the bowels freely. Copious enemata with normal saline,
and by the month frequent small doses of alkaline carbonates and citrates
may be tried.

§ 198« HsBmatemaiiB (Vomiting of Blood). — Bleeding from the stomach,
unless in slight quantity, is usually accompanied by nausea and vomiting.
In the first place, it is important to decide whether the blood really comes
from the stomach and oesophagus.

Sources of Fallacy, — (1) Blood from the lungs may be mistaken for
blood from the stomach (see Hsemoptysis, § 73). (2) Epistaxis, the blood
running down the gullet and being vomited, is a common fallacy in
children, in whom the blood is apt to be swallowed. The same may
follow operations on the tonsils or teeth. Epistaxis is recognised by making
the patient blow his nose. In epistaxis there are no abdomiual symptoms.
(3) Blood from thQ fauces or gums, especially when the gums are spongy,
or when pyorrhoea alveolaris exists, may give rise to a sanguineous vomit-
ing or expectoration, the cause of which is very apt to be overlooked, if
unsuspected, even by competent observers^ (§ 145) ; but the blood is
mixed with saliva, and is rarely very large in amoimt. (4) Blood from a
fracture of the base of the skull and from cesophageal disease may also be
swallowed and vomited. On the other hand, hcBmorrhagefrom the stomach
is (i.) preceded by a feeling of faintness and nausea, and (ii.) followed by
melsBua (tarry stools), (iii.) Blood from the stomach is mixed with food,
and mostly brown (" coffee-grounds "), though it may be red if the quantity
is large {e,g,, in ulcer) or if food has been brought up before the blood,
(iv.) There is an absence of previous history or local signs of pulmonary
disease, and there may be a previous history of disease or derangement
of the stomach or liver.

The Causes of Hcsmaiemesis may be roughly divided into (a) those
which produce a slight or protracted hsemorrhage, and (6) those which
give rise to a large quantity at one time.

(a) fflight or Protracted HsBmorrhages occur chiefly in Chronic Gastritis
and Cancer. A temporary irritation or congestion of the stomach produced
by irritating articles in the food or by urgent vomiting, may be attended
by streaks of blood in the vomit.

I. Chronic Gastritis, or gastric catarrh, is known by (i.) vomiting
in the morning — often viscid mucus streaked with blood — or at other
times, (ii.) It may be accompanied by, and due to, disease of the liver
(cirrhosis), or advanced cardiac disease, and is foimd especially in alcoholic
subjects (see § 209).

II. Cancer op the Stomach or (Esophaqus is recognised by : (i.) The
patient is usually beyond middle age ; (ii.) pain is complained of — severe,
constant, and genercdly worse after food ; (iii.) the blood vomited is rarely
copious, but tjrpically " coffee-ground " in character, and may continue for

^ Gases of this kind, mistaken at first for oreanio disease of the stomach and the
longs, have been recorded (see Report Roy. Med. Ohir. Soc., Lancet, June 16, 1900).

274 THE STOMACH [ § 102

weeks ; (iv.) the hsematemesis is very rarely followed by melsBiia, because
the blood is scanty, and because there is often obstruction of the pylorus ;
(v.) progressive cachexia is marked, and an abdominal tumour, or evidence
of cancer elsewhere, may be foimd (see also § 208).

(6) A Large HsBmoirhage at one time may occur in Simple Ulcer of the
Stomach or Duodenum, Liver Diseases, other diseases giving rise to Portal
Obstruction, Aneurysm of the Aorta, Vicarious Menstruation, Gastrostaxis,
Morbid States of the Blood, or after taking Chemical Irritants.

III. Simple Uloee op the Stomach. — This is known by : (i.) The

hsematemesis is copious; therefore the blood is bright red, after first

being a little black, and melsBua usually follows ; (ii.) characteristic pain

occurs directly after food, and is relieved by vomiting ; (iii.) it is found

chiefly in young women, (iv.) who are the subjects of anaemia, but not

often great emaciation ; (v.) a history of previous attacks of bleeding is

often present (§ 207).^

Ilia. Uloeb of the Duodenum is often difficult to distinguish from gastric ulcer.
It occurs mostly in men.

IV. Liver Disease (by causing portal obstruction), especially gibrhosis
(§ 250). The hsematemesis may be slight, but it is more often very
copious — ^the most copious met with.

V. Other Causes op Portal Obstruction (see § 233) — e.g., tumour
pressing on the portal vein. This, as with cirrhosis, is known by the
other symptoms of such disease — e.^., (i.) the accompanying and rapidly
increasing ascites, and (ii.) diarrhoea.

VI. Aneurysm op the Aorta, or of one of its branches, leaking into
the bowel, or oesophagus. This is known by (i.) possibly a previous
history of aneurysmal symptoms (§ 53) ; (ii.) the blood is copious ; (iii.) sud-
den death is the usual result. This is the usual course, but in certain
other cases there is a small recurrent leakage from the aneurysm for a
few days or weeks preceding death.

VII. Vicarious Menstruation. — It is impossible to be certain in the
diagnosis of this condition. Its leading features are that it occurs periodi-
cally, and in women with amenorrhoea.

VIII. Gastrostaxis. — Under this title are included cases of severe
haBmatemesis, occurring usually in young anaemic women, due to capillary
oozing. Such cases were formerly thought to be due to gastric ulceration,
but more frequent operations and post-mortem examinations have shown
that no ulcer is present.

IX. Morbid Conditions op the Blood, such as yellow fever, malignant
forms of the specific fevers, purpura, leuksemia, and haemophilia.

X. Chemical Irriiants (e.g., mineral acids), or mechanical injuries
from articles which have been swallowed.

In the Differentiation of the causes of hsematemesis (1) examine the

^ Cases have been reooided of profuse hsmatemesis resembling that of simple ulcer,
occurring in older patients, which disappeared under antisyphilitic treatment. The
condition was apparently a syphilitic ulcer of the stomach. — Dalgleish, Lancet, 1898,
voL ii.. p. 410»

1198] CAUSES OF HMMATEMESIS 275

stomach ; (2) examine the liver, especially for Cirrhosis, which is perhaps
the commonest cause of hsBmatemesis, simple or malignant ulcer being
the next ; (3) ascertain the approximate quantity of vomited blood, and
then review the case.

Prognosis, — Hsematemesis is usually a serious sjrmptom, but its gravity
depends upon the cause. In portal congestion, hsematemesis not infre-
quently serves as a safety-valve to relieve the abdominal congestion, and
in a sense is beneficial. As regards the lesion, aneurysm is the most
grave of the causal conditions; then, in order, cancer, morbid blood
states, cirrhosis, and simple ulcer. The amount of haemorrhage is a less
valuable guide tb prognosis, although where the amount is copious the
patient will remain debilitated for a considerable time.

The Treatment of haematemesis must also have reference to the cause.

(a) When small in quantity, it calls for but little immediate treatment.

(b) When in larger amount, the patient should not be moved hrom the
place where the bleeding occurred, but must be kept absolutely at rest in
the horizontal position. An ice-bag should be placed over the epigastrium.
Nothing should be given by the mouth except iced water for some time
(see Gastric Ulcer, § 207). Morphia hypodermically is the best haemo-
static, and also relieves anxiety and pain. If bleeding continues, give
astringents by the mouth, such as alum (gr. v.) and dilute sulphuric acid
(n^^xx.), or ergot. Adrenalin (1 iji 1,000), J-drachm doses every two or
three hours, is a recent and valuable remedy. Normal serum is also
recommended by some. In profuse haemorrhages saline transfusion may
be necessary.

§ 193. The other Local Symptoms of gastric disorder are of considerable
diagnostic value.

1. Bad Taste in the Mouth is very often complained of in gastric
disorders, and is always most noticeable in the morning. Dryness of
the Lips is another very constant manifestation, and will often give an
acute observer the first clue to the existence of gastric disorder.

2. Thirst is often associated with dyspepsia; it is specially apt to
occur with dilatation of the stomach, inflammatory stomach lesions, and
in all cases where there is persistent vomiting.

3. Flatulence is a distension of the stomach or intestines by gas,
which may be brought up by the mouth or passed by rectum. This gas
may be due to repeated swallowing of saliva and air, as in chronic gastritis,^
or to decomposition of food. Among its causes are excessive ingestion of
vegetables, sugars, and starches, chronic dyspepsia, or chronic gastritis,
and all conditions attended with dilatation of the stomach.

4. "Heartburn" and Acid Eructations are usually met with
together. Heartburn is a burning sensation passing up from the epi-
gastrium to the pharynx, and sometimes mouthfuls of acid fluid are brought

^ The eemi-voluntaiv swallowing or gulping down of air (aerophagy) is met with in
lunatics, and in some hysterical or neurotic individuals without gastric derangement.
It is diagnosed from dyspepsia by the absence of all other symptoms of that condition.

276 THE 8T0MA0H [ § 198

up at the same time. It is due to hyperacidity and partial regurgitation
of the gastric contents into the lower end of the oesophagus. The treat-
ment of 3 and 4 is discussed in § 204.

Causes, — ^Hyperacidity, or "acid risings," may be of two kinds,
(a) Organic acids are met with in diseases where tJiere is deficient gastric
secretion — some forms of atonic dyspepsia, chronic gastritis, cancer, and
dilatation of the stomach. HC3 is a germicide, and when from any cause
it is absent, bacteria flourish ; fermentation ensues within Skfew hcurs after
food, and is accompanied by pain in the epigastrium. The three principal
types of acid fermentation are : butyric, lactic, and acetic.

(h) Hyperchlorhydria, or excessive secretion of BCL This condition is
met with in one form of acute dyspepsia, and chronic glandular gastritis.
The name is often misapplied to the acidity due to organic acids arising
from fermentation. Hero, the pain or " gnawing " generally occurs before
meals, and is temporarily relieved by food (see also § 205).

5. Hiccough. — Normally the opening of the glottis synchronises with
the contraction of the diaphragm, and consequently there is no hindrance
to the free entry of air. Hiccough is caused by a spasm of the diaphragm
which occurs at irregular intervals and sometimes at the moment of closure
of the glottic aperture. The characteristic cough is then heard. The
important causes of persistent hiccough are : (1) Reflex stimulation of the
phrenic nerves by gastric flatulent distension or irritation after hot,
peppery foods and with hepatic disease. (2) Irritation of the peritoneum,
as in peritonitis, general or local, near an inflamed abdominal organ, or
in typhoid fever. (3) Disease of the thoracic viscera, especially dia-
phragmatic pleurisy. (4) Toxic blood conditions, notably ursemia.
(5) Neurosis. To this cause are assigned certain cases for which no more
adequate reason is apparent. Hiccough may also occur as a symptom of
hysteria, of cerebral tumour, and meningitis.

Prognosis, — Hiccough is not as a rule a symptom of any great sig-
nificance. In abdominal disease its occurrence is of grave import. Occa-
sionally it may be persistent and resist all treatment; it exhausts the
patient, and may be the immediate cause of death.

Treatment, — The simplest forms of treatment are those directed to
producing definite physiological contractions of the diaphragm. These are
such well-known methods as sipping water and holding the breath. Any-
thing which gives rise to a feeling of suflocation may cause a forcible con-
traction of the diaphragm, and so stop the spasm ; for this reason tickling
the nares and taking snufi have been tried, often with success. Dyspepsia
is the most common cause in operation, and the hiccough is readily cured
with bicarbonate of soda and peppermint. If these measures do not
suffice, or if the hiccough recurs frequently, a thorough investigation of the
patient is called for. When no causal condition can be found and the
hiccough continues to be severe, one may give sedative drugs by the mouth
or, if necessary, by the rectum ; the bromides and tinct. opii or -^-^ gr. apo-
morphine subcutaneously are successful. Peripheral stimuli, such as blisters

1 104 ] S YMPTOMA TOLOQ Y 277

to the epigastrium, pinching the lobe of the ear, forcible pulling forward of the
tongue, and digital pressure on the vagus in the neck, may be tried ; and
the abdomen may be bound tightly with a bandage or with plaster.
Chloroform may have to be administered. Of drugs, the opiates, those of
the acetanilide group and the nitrites have most often been of use.

6. "Water-brash" (Pyrosis) is the name given to a dear alkaline
fluid expelled from the mouth in gushes, most often in the morning.
Sometimes it is expelled without any kind of straining, but more often
it is attended by retching. It is probably a reflex hypersecretion of saliva
due to irritation in the stomach, swallowed during the night. It is met
with in many dyspeptic conditions, and is a fairly constant symptom in
chronic gastritis.

7. Anorexia (Loss of Appetite) is not always an indication of stomach
disease, as it is present in many general constitutional disturbances. Its
chief clinical importance lies in its presence in the earliest stage of gastric
cancer. In atonic dyspepsia there is sometimes no appetite before a meal ;
but the first few mouthfuls of food induce secretion of gastric juice, and
so excite appetite. Hysterical Anorexia ( Anorexia Nervosa) is known
by : (i.) The appetite is perverted ; for instance, the patient will only eat
some unreasonable article — e.g., a penny bun bought at a particular shop.^
Such patients may push matters to extremes, almost to the point of
death. The condition is really a form of hysterical insanity, (ii.) It is
only met with in the female sex, and (iii.) the hysterical stigmata are
generally present (Chapter XIX.).

Increased Appetite is far more often met with, as Shakespeare pointed
out, in gastric disorders. It is found in some cases of chronic dyspepsia
chronic gastritis, and dilated stomach, in pregnancy, and during con-
valescence. A FALSE appetite which is satisfied with the first few mouth-
fuls of food is sometimes met with in subacute and chronic gastritis, owing
to the irritated condition of the mucous membrane. Boulimia or ravenous
appetite is seen in diabetes, in neuroses of the stomach, after acute gastritis,
in wasting disorders such as mesenteric gland disease, in phthisis, intestinal
worms, and Graves' disease. Perverted appetiib, excessive fondness
for acids and sweets, or desire to eat objects such as chalk, pencils, or hair,
may occur in hysteria, chlorosis, and pregnancy. A foul breath is present
in some forms of gastritis. It has been proved to be due in some cases to
an infection of the stomach wall by streptococci and B. coli.

§ 194. General or Remote Sjrmptoms are very constant accompaniments
of all gastric diseases.

1. General Malaise and a sense of ill-health and incapacity for work
are among the earliest and most constant accompaniments of all derange-
ments of the digestion, whether functional or organic. The dark rim
beneath the eyes, and the sallow, "earthy" complexion, so frequently
associated with town-dwellers, are quite as often due to dyspepsia, just as

^ An instance of this kind has happened in my experienoe, and the patient, thin as
a skeleton, was really on the point of death when I first saw her.

278 THE STOMACH [ § 104

this latter is often due to defective teeth or to the insufficient use of them.
Emaciation is not so frequently associated with gastric disorder as might
be supposed, though in very chronic cases there is sure to be some loss of
flesh. Early and marked emaciation is, however, one of the surest indica-
tions of cancer of stomach.

2. The Cardiac Symptoms met with in dyspepsia are palpitation, pain
in the region of the heart (pseudo-angina) ; dyspnoea, syncope, and vertigo ;
intermission of the cardiac rhythm ; and cough, due to pharyngeal catarrh
or reflex irritation. Collectively, these sjrmptoms may, as previously
mentioned, give rise to the impression that the case is one of cardiac
valvular disease, although the heart may be structurally healthy.

3. Functional Disturbance of Nervous System. — Headache and
degression of spirits are invariably met with in all forms of dyspepsia.
A sense of general ill-health and irritability of temper out of all propor-
tion to the local mischief attend most gastric disorders, and, where
stomach symptoms are not prominent, may lead the physician away from
i he true cause.^ Any or all of the symptoms of neurasthenia (Chapter XIX.)
may undoubtedly result from gastric disorder, and this constitutes one
variety of what the author has described as Toxic Neurasthenia.^

4. DiARRHCEA may accompany stomach disease when the gastric con-
tents are of an irritating nature ; Constipation is usually found with

'Ngynple ulcer, cancer, and chronic gastritis. But a more usual condition
is an IRREGULARITY of the bowels, accompanied by borborygmi (rumbling
in the bowels).

5. The Urine invariably exhibits signs which reveal the disturbances
in the metabolism of the body. The commonest of these, perhaps, is an
excess of urates, as shown by the pinkish sediment when the urine cools.
In other cases phosphates form the deposit ; and in certain cases oxalates
are found (compare § 314). In these circumstances dyspepsia must be
regarded as a predisposing cause of renal and vesical calculus.

6. Skin Symptoms. — General prurittis may accompany many forms of
gastric derangement. Flushing of the face after meals is met with in
many gastric disorders, especially when they occur in the female sex. The
face may be swollen so that the case appears like one of acute Bright's
disease ; but the sudden onset, without much constitutional disturbance,
and early disappearance on curing the indigestion, distinguish it from that

^ Gautier and others have shown that certain toxins are being constantly generated
within the body, and especially in the digestion and metabolism of the food. They
produce no evil effect in health when not in excess, partly because they are excreted
by the urine, faeces, and sweat, partly because they are being constantly destroyed
(chiefly, perhaps, by the liver). But when in excess they produce profoimd disturb-
ance of uie general economy, and especially of the nervous system. Their compo-
sition, as far as we know, is analogous to the vegetable alkaloids (morphine, atropine*
etc.), and they are therefore known as animal alkaloids. There are two kinds —
(1) Ptomaines, which are produced by the fermentative disintegration of t^ead albu-
minous substances {e.g., during digestion) ; and (2) Leucomaines, which are produced
by the activity of living nitrogenous substances (see also Sir Lauder Brunton in the
Practitioner for October and mvember, 1880).
^ '' Clinical Lectures on Neurasthenia,'* Glaiaher, London.

§{ 196, 196 ] PH Y8I0AL EXAMINATION 279

disease. The occurrence of general urHcaria in certain individuals after
eating indigestible articles is very common. It may also attend the
different forms of gastric disorder.

PART B, PHYSICAL EXAMINATION.

Disorders of the stomach are investigated by Inspection, Palpation,
Percussion, Auscultation and Ausculto-percussion, and by Examination of
matters vomited, or withdrawn from the stomach by a tube.

§ 195. InspeotioiL (1) The Teeth in all cases must be closely examined.
Among my out-patients the two commonest causes of indigestion are
certainly defective teeth and bolting the food. Disorders of the teeth
are referred to in § 143 and § 145.

(2) The Tongue and its diseases have been already described, and § 147
should be specially consulted. At one time the tongue was thought to
indicate the state of the stomach, but this is by no means always the case,
and it is a far more certain indication of the patient's general condition.
But even in this, allowance has to be made for certain variations — namely :
(i.) Individual variations, since a coated tongue is normal to some, even
in health, and a clean tongue in others may be associated with disease ;
(ii.) certain diets — e,g,, milk — produce a coated tongue ; and (iii.) certain
habits — e.^., smoking and " tippling " — also coat the tongue. The mouth
may show signs of acid poisoning.

(3) Inspection of the epigastric region may reveal a tumour, or the
peristaltic movements of a dilated stomach. Aortic pulsation may be
transmitted by a pyloric tumour, although no bulging is visible.

(4) In skilled hands the oesophago-gastrosoope may be employed to examine the
interior surface of the stomach.

§196. Palpation. — To palpate the stomach successfully requires con-
siderable experience. The patient's shoulders should be supported, and
he should be instructed to open his mouth, to draw up his knees, and to
" let his breath go." ^ Talking to him is useful to distract his attention.
The hand should always be warmed, and it should then be laid quite flat
upon the abdominal wall. Then only can we detect the presence of a
tumour, tenderness, or other abnormality.

Gastric Siiccusaion or Splashing is made out by placing one hand on
each side of the stomach, and suddenly pressing inwards the finger-tips
of each hand alternately. Listening over the stomach with a binaural
stethoscope during this procedure materially aids in discovering this sign.
Splashing can be normally elicited during the process of digestion — i.e.,
during the first hour or two after a meal, especially if much fluid has been
taken. But if succussion can be elicited after that time, it suggests that
there is atony of the stomach, either with or without dilatation.

^ Some say it is better to have the legs extended loosely, and some advise ezamina*
tion in a hot bath to relax the muscles. Finally, anaesthesia with chloroform or ether
may be necessary in very obscure cases.

280 THE STOMACH [ §§ 197, 198

§197. PercDSfflon of the stomach is not very satisfactory or precise.
The only diseases in which the area of stomach resonance has to be defined
are Dilatation (§ 210), and Gastroptosis (§ 211).

Pebgussiok 07 THE Stomach. — ^The normal stomach is depicted on p. 362, and its
situation in Fig. 60, p. 237, the oaidiao orifice being under the seventh costal carti-
lage, about an inch to the left of the sternum. The pylorus is just to the right of the
sternum, and 2 inches below it. The lesser curvature corresponds closely to a line
drawn round the tip of the xiphoid cartilage and along its left side. The fundus of
the stomach is its highest point, and is just behind the heart apex at the fifth rib.
The position of the greater curvature (lower border) of the stomach varies according
to the degree of distension ; it ought not to come lower than midway between the
umbilicus and xiphoid. Its position is hard to define, owing to the proximity of the
transverse colon. Traubo's space is the name given to the area of resonance to the
left of the left costal maiigin, the position where the stomach is in direct contact with
the chest wall. Only the lower border and part of the anterior wall of the stomach
are normally in contact with the abdominal parietes. The percusson note over the
stomach is tympanitic, but has rather a lower pitched tone than that over the trans-
verse colon, which is, of course, also resonant.

The rough outline of the stomach resonance can be made out by percussion in the
usual way without any elaborate precautions, but the following method is more
accurate : The stomach being empty, let the abdomen be stripped, with the patient
standing. Percuss lightly from above downwards, and mark the change of note«
the stomach being usually the most resonant of the abdominal viscera. After this
give the patient a large drink of water. The note over the lower border of the stomach
is now dull, and the lower level of the dull note so produced can be marked. Finally,
the area of the stomach can be percussed out, with the patient in the recumbent
posture, when the lower boundary will be found at a different level.

Auscvlto-percussion is sometimes employed to define more accurately the boundaries
of the stomach. Place the stethoscope in the angle between the xiphoid cartilage and
the left costal margin, and elicit the normal stomach note by percussing or gently
stroking the skin near it. Then stroke from the periphery of the abdomen towards
the stomach ; the note changes and conveys a definite sense of impact to the ear as
soon as the border of the stomach is reached. When there is fluid in the stomach,
the percussion note varies with the position of the fluid, and then it is necessary to
percuss the boundaries, first with the patient lying on his back, then on his right,
and finally on his left side.

When possible, the X rays are employed to detect the precise position of the lower
border of the stomach (see { 198).

Fallacies. — (1) Apparent enlargement of the stomach may arise in contracted
cirrhotic liver, or fibrosis of the lung. (2) Apparent diminution may occur when the
liver is enlarged or pleuritic effusion is present. (3) Dislocation of the stomach down-
wards may simulate dilatation. In such cases the lesser curvature may sometimes be
seen or felt below its normal position.

§198. Motor Insufficiency of the Stomach (Grastric Atony or Myas-
thenia) leads to Dilatation (§ 210). A man can live and maintain weight
without the secretory and resorptive functions of the stomach being quite
perfect ; but serious auto-toxic effects and mabiutrition result from a
retention of food within the stomach. Moreover, motor insufficiency is
always attended sooner or later by disturbance of the secretory and
resorptive powers.

After a normal meal, consisting of 60 grammes of bread, 200 grammes of beefsteak,
and a glass of water, no solid portions should be found in the stomach in six or seven
hours. There is, however, considerable individual variation. Recently X rays have
been found to give reliable information of the motor functions of both the stomach
and intestine. Two ounces of bismuth carbonate are given with breakfast, mixed
with arrowroot, milk, or minced meat. This produces a definite shadow when

§ 190 ] EXAMINATION OF STOMACH CONTENTS 281

examined with the fluorescent screen, and so its passage down the alimentary canal
can be observed. Thus motor weakness, dilatation, or obstruction may be detected.
Carbohydrates have thus been shown to leave the stomach in three hoars, whilst
proteids and fats are still present in small amount after six. The average time for
the bismuth breakfast to reach the csBcum is four and a half hours, the splenic flexure
nine hours, and the sigmoid flexure twenty-six hours.

§ 190. Examination of Stomach Oontenti.^ — ^First as to the Chbmistby of Dioes-
TiOK, from a clinical standpoint, and the practical information to be derived from
clinical examination of the stomach contents. Four processes normally take place in
the stomach : (1) The conversion of starch into sugar, begun in the mouth, is carried
on a stage farther ; (2) proteids are changed into peptones ; (3) fat globules are set
free from their envelopes ; (4) milk is curdled. Delay in digestion may be caused by
(1) deficient peristalsis of the stomach walls, (2) deficient quality or quantity of the
gastric juice, (3) the consumption of indigestible articles, or (4) the dilution of the
gastric juice by drinking too much fluid at meal- time.

The gastric juice contains HCl, water, pepsin, rennet, mineral salts, and a liUle
mucus. Pepsin and rennet exist in the secretory cells only as zymogens, which,
in the presence of the HCl, become active ferments or enzymes. In ^e healthy state,
as iAio result of digestion, about 30 c.c. of fluid should be obtained from the stomach
one hour or so after a test-meal (vide infra), straw-coloured, without much odour,
without organic acid, and with about 0-2 per cent, of free HCl.

As regards hydrochloric acid, much depends on the time of examination. Hyper-
chhrhydria is merely a convenient term for excessive secretion of HCl. It has come
to be somewhat loosely used for " excessive acidity," and thus to be confused with
the acidity of fermentation (due to organic acids). On the other hand, after a meal,
a negative result on testing for HCl would indicate the absence of peptic activity, as
an acid is required to convert the inactive proenzyme or pepsinogen into pepsin. An
excess of HCl is distinctive of gastric ulcer, as compared with gastralgia ; for in the latter
the HCl is normal or diminished. HCl is also diminished in all catarrhal conditions
of the mucous membrane, in great anaemia, and neurasthenia. When there is a difii-
cnlty in diagnosing malignant disease, the absence of free HCl is a point in favour of
cancer.

Lactic acid is not normally present in the gastric juioe after digestion has proceeded
for one hour, but traces may be found, due to the ingestion of lactic acid in certain
foods, or to fermentation in the mouth. A decided reaction with Ueffelmann's test
(infra) is found with cancer of the stomach, but a negative reaction does not have
equal value in proving the absence of the disease.

Butyric and acetic acids prove the presence of fermentation, and are found where
HCl is deficient, or the food is delayed in the stomach, as in dilatation of the stomach,
or a narrowing of the pylorus.

The secretion of pepsin, according to most authors, is not interfered with, unless
there be destruction of the glandular elements of the stomach. The presence of pepsin
is also indicative of the presence of HCl (which is necessary to convert pepsinogen into
pepsin), and of the activity of the glands. If only pepsinogen is found, the glands
are active, but HCl is deficient. The presence of the latter (pepsinogen) is an im-
portant feature in diagnosing between chronic gastritis, where the glands are destroyed,
and dyspepsia, or any neurosis of the stomach, where tht glands are not destroyed.

Benninogen and Bennin are diminished or absent in the later stages of gastritis and
cancer. The amoimts of renninogon and rennin present appear to be directly pro-
portional to the quantities of pepsinogen and pepsin.

Summary. — ^The two most important questions, therefore, to determine in an
analysis of stomach contents are : (1) The presence and amount of HCl ; and (2) the
presence and amount of pepsin and pepsinogen. The latter question is specially
important, because —

(a) If the ferments present are chiefly pepsin and rennin, the gastric glands are active,
and HCl u) not deficient, since this is required to convert pepsinogen into pepsin.

^ It is not possible hero to give more than a brief outline of this important subject,
and the excellent treatises of Hem meter and otliers on Diseases of the Stomach may be
consulted with advantage.

282 THE STOMACH I } 199

{h) If thefarmtntt pruent are chitfiy peptirtogen and renninogen, the gutrio gUnds
are active, but the ECl ia defioient.

*"™Hitimi ol OMtrlo Contenb after a Telt-Meal ia a luefal method of investiga-
tion in casea of eevere and intraotable imJigeelioii or dilated stomach, or when oancor
ifl auspecfad. It consists of three atopa : (a) Tho adminiatnition of the teat-moal ;
(b) the withdrawing of tho gastric content* by moans of a atomach-tube ; and (c) tho
microscopical and chemical examination of the material withdrawn.

(a) The taal-maaU Buggeatod are of many kinds, but the following anawora ; A pint
of woak tea ([nfusod only two or throe minutes), with tho addition of not more than
1 ounce of milk, and eugar if doBirod, or a pint of thin arrowroot, mado with water
ami about 2 ounces of milk, sugar being added to ta«t«. With thaso a round of thin
buttered toast should be taken. Tho test-meal should be given in the morning before
any food ia taken, and drawn oS an hour and a half later.^

(b) Methol ol FMfiiiE the Tnbt.~U«i a rubber tube nearly 2 yards long, with Urge
" eyoB." It should bo thoroughly cleaned, and moistened with warm water or
glycerine before being passed into the phaiyni. The patient should sit widi the hoad
erect, the chin being projected forward, and tho mouth open. The tube ia passed into
the pharynx, whiki the patient ia inatructed to swallow, and the tube is pnabed down
into tho atomaoh. Then bring tho end down to a lower level than tho atomach, and
the conlonte ahould siphon out into a receptacle. If tho gastrio content* do not

Ytmt fnngiii bas a aimllar BlgnlHcance,

flow at once, the patient should strain, aa if trying to vomit ; or draw out the tube a
little, leat the end beoomea folded upon itself, or the " eye " stopped by a fold of
mucooa membrane. It may bo noceaaary to start the flow by suction with a syringe.
The tube should bo marked at a poaition 16 inches from i(a tip. By this meana we
know the amount of tube nhich has been passed into the ceaopb^us, hscauea when tho
mark is opposite tho incisors, the tip ought to have reached tho atomach. A fieiibte
tube curling up in the cesopbagua is a contingency which may thas be obviated. Its
use is contra-indicaUd in angina, heart failure, fevers and other aouto discaaea, recant
hemorrhages, great arterio-sclorosia. aneurysms, and a high degree of emphyaoma and
bronohitia.

(e) Examination ot Stomaoh Ooiitaiiti after the test-meal.

GJESKKAL ExAHiNATiDM. — Appearance, acidity to litmus paper, amoll, conaisteDey,
and presence of slimy mucua, bile, or bk>od, ahould first be observed.

HidtoscopiCALLY (Fig. 61) we can detect fat globules, starch colls, vegetable and
muaolo fibrea, and sometimes fatty crystals, leucin and tyiosin. colls of the mncous
membrane, lonile corovisiic, or sarcinee. and pus cells. Epithelial calls are present
in excess in oarcinoma. Tho Oppter-Booa baoillua may sometimes be seen on examina-
tion under the high power.

> Dr. W. H. Wileoi, Lancet, Jtme 10, 1906. and July 25, 1908.

§ 199 ] EXAMINATION OF STOMACH CONTENTS 283

The stomach oontents ahonld be filtered, and the filtrate used subsequently.

ChbmicaIiLT we have to answer eight questions :

(a) Are the contenia acid f can be roughly detected by the use of carefully neutralised
litmus paper.

(6) Metiiod of etAimaiing ioUd acidity — f.e., acidity due to hydrochloric acid, organic
acids, carbon dioxide, and such acids as react acid to phenolphthalein. Titrate 10 c.o.
filtered gastric contents with decinormal solution of caustic soda (prepared free from
carbon dioxide), using 1 per cent, solution of phenolphthalein as indicator. Add a
drop or two of the indicator to the gastric contents, dilute with two or three times its
volume of distilled water, and then run in the decinormal caustic soda solution from
a burette till further addition produces a faint purple-red tint. If 5*5 c.c. of deci-
normal caustic soda are required for 10 c.c. of gastric contents, the acidity may be
calculated in terms of HGl by multiplying the 5*5 c.c. of the soda solution used by
0*00364 X 10. The percentage of HCl actually present is therefore 10 x 5*6 x 0*00364
= 0*2 per cent.

(c) lefru hydrochloric acid present f Tests : (i.) A 1 per cent, solution of di-methyl-
amido-azo-benzene in alcohol is used. A drop of gastric oontents is placed on a white
tile, and a drop of the reagent run alongside. A deep pink-red colour is given by free
HCl. (ii.) Gunzberg's test : Two or throe grains of phloroglucin aro mixed in a small
evaporating dish with 1 or 2 grains of vanillin, about 1 c.c. of alcohol is added, and then
about 1 C.C. of gastric contents. Evaporate on a water-bath, when a bright cherry-
rod colour indicates froo HCL If much organic acid is prosent. a slight reaction may
occur in test (i.), which, though more convenient, is therefore not quite so reliable as
test (iL), which is never given by organic acids. Free hydrochloric is normally present.
It is always present in gastric ulcer and hyperchlorhydria, hardly ever in caroinoma.
{d) What is the amount of active hydrochloric acid f The ** active ** hydrochloric acid
includes (i.) free HCl ; (ii.) the HCl which is combined with proteid and nitrogenous
organic bases. It does not, of course, include the inorganic chlorides like NaCL
EstimaHon. — ^Two equal volumes of the filtered gastric contents (10 c.c.) arc taken,
(i.) One portion is made alkaline with sodium carbonate solution and evaporated to
diyness on a water-bath in an evaporating dish. The residue is ignited over a small
Bnnsen flame until it is well charred and all the organic matter is decomposed. (iL ) The
other portion of the gastric contents is placed in a porcelain evaporating dish (4^ inches
in diameter), and evaporated to dryness on the water- bath, as in (i.). In each case
the dish is cooled, and about 60 c.c. of water, 6 c.c. of pure nitric acid, 3 c.c. of 10 per
cent, iron alum solution, and 10 c.c. of decinormal silver nitrate solution, added.
Decinormal ammonium sulphocyanide solution is run in until a permanent brownish-
red tint appears. The active HCl in 10 c.c. of gastric contents is equal to the difference
of the amounts of ammonium sulphocyanide solution used in (L ) and (ii. ). Example. —

If in (L) 3 C.C. of — sulphocyanide solution are used, and in (ii.) 8 c.c. of ,^^ sulphocyanide

solution are used, then the active HCl in 10 c.c. of gastric contents is 5 c.c. of ^ HCL

Therefore the percentage is 10 x 5 x 0*00365=0*18 per cent. This is the most im-
portant estimation, and the amount normally is about 0*15 per cent. In carcinoma
it is usually much hdow 0*1 per cent. ; in simple ulcer it is usually considerably above
0*15 per cent. It is the most important estimation in the analyses of gastric contents.

(e) Is lactic acid present f A qualitative test should be made, a weak solution of
Ueffelmann*s reagent (made by mixing a little 5 per cent, solution of carbolic acid with
a few drops of liquor ferri perohloridi) being added to the filtered gastric contents.
The development of a distinct yellow colour indicates lactic acid.

(/) Wha is the amount of organic adds ? This is given with sufficient accuracy by
the difference between the total acidity (expressed as HCl), and the active HCl as
estimated by the method described above. They are in excess in conditions of much
fermentation and gastric caroinoma.

(g) Is mucin present in the filtrate f To the filtrate add an equal volume of distilled
water, and then a 2 per cent, solution of acetic acid, drop by drop. A whit precipitate
indicates the presence of mucin. It is always present in caroinoma, and sometimes
in simple gastritis ; usually absent in gastric ulcer.

(h) What is the ferment activity f The pepsin and pepsinogen may be roughly gauged
by the carmine-fibrin test ; the rennin and ronninogen may be estimated quantita-

284 THE STOMACH [ § 199

tively. The Carmine-Fibrin TeaO — ^Three test-tubes aro taken containing rospoc-

tively (1) 4 o.o. of gastric contents ; (2) 2 c.c. of gastric contents and 2 o.o. of 0*4 per

cent. HCl ; and (3) 2 c.c. of gastric contents and 1 c.c. of water. A few shreds of

washed carmine fibrin are placed in each, and the test-tubes aro incubated at 37^ C

The test-tubes are shaken every few minutes, and the depth of red colour present

indicates approximately the quantity of pepsin present. EsHmation of Rennin and

Benninogen, — ^The following method is exceedingly simple and well adapted to clinical

purposes : Narrow test-tubes, 5 inches by } inch, are taken. Into each 5 c.c. of fresh

unboiled milk are added. They aro placed in a water-bath at 40° C. Into the tubes

are placed seriatim gradually increasing quantities of the filtered gastric contents.

These are run in from a pipette, which is graduated in -^ J^ths of a cubic centimetre.

Thus are added 0-01, 0-05, 0-1, 0-15, 0-2, 0-25, 0-3, 0-35, 0-4, 0-5, 0-6, 0-7, 0-8, etc.. of

gastric contents. The liquids are mixed by gently inverting each tube. The tubes

are left thirty minutes in the bath, and then it is found that above one point in the

series the contents of the tube are solid, and do not flow out on inversion, while below

this point the contents are liquid, and flow out on inversion of the tube. The minimum

quantity of gastric contents to cause complete clotting, so that the contents of the

test-tube do not flow out on inversion, gives an accurate measure of the rennin activity.

In the normal gastric contents of adults about 0*2 c.c. is required ; in children a gpiBater

amount is normally required. If X=the minimum quantity of gastric contents to

cause complete clotting, then the quantity of rennin present in the gastric contents =

0-2

-— of the normal amount ; e.g,, if 0*05 c.c. of gastric contents was the minimum

0'2
amount to cause complete clotting, the quantity of rennin present =^—= four times

the normal. In gastric carcinoma usually much more is required — e,g,» 0*5 c.c, or

more. Possibly no complete clotting will occur at alL In gastric tUcer and hyper-

chlorhydria the rennin activity is usually higher than normal, and never below normal.

Often 0*05 c.c. or less causes complete dotting. In cases where the acidity of the

gastric contents is low, and also the ferment activity, most of the ferment is frequently

present as renninogen, and not as rennin. In these cases the above method of analysis

should be adopted for the estimation of the rennin, and a separate estimation made for

the rennin plus renninogen. The renninogen can be estimated by taking the gastric

contents, adding an equal volume of 0*4 per cent. HCl, which converts the renninogen

to rennin. The same procedure is adopted as above — ^viz., the addition of the mixture

of HCl and gastric contents in increasing quantities to the milk in the test-tubos

respectively, and the minimum amount of the mixture which will cause complete

clotting, so that the contents do not flow out on inversion, is noted. In the normal

gastric contents of adults about 0-1 c.c, when mixed with 0-1 c.c. of 0*4 per cent.

HCl, is the minimum quantity which will clot completely 5 cc of milk at 40*^ C. in

half an hour; with children a greater amount is necessary. If X=the minimum

quantity of the gastric contents which, when mixed with 0*4 per cent. Hd, will cause

clotting (t.e., half the amount of the mixture taken), then the quantity of rennin plus

0*1
renninogen present =n^ of normal ; e,g., if in a given case 0-1 c.c. of the mixture of

gastric contents and 0*4 per cent. HCl was the minimum amount to cause complete

clotting, then, since 0-05 c.c = the quantity of gastric contents in 0*1 c.c. of mixture.

0-1
the quantity of rennin plus renninogen present= . =2 times normal. Sometimes

where the rennin is below normal the renninogen plus rennin are found to be normal.
This would contra-indicate a condition such as gastric carcinoma. The importance of
the estimation of the rennin is accentuated by the fact that the amount present is
usually directly proportionate to that of the pepsin.

* The remainder of tliia section is largely composed of a quotation from the Lancet,
1908, vol. ii., p. 220, by Dr. Wilcox, to whom tlio author is greatly indebted for valuable
help in its preparation.

§! 800» 201 ] AOUTE D 78PEP8IA 285

PABT a DISEASES OF THE STOMACH, THEIR DIFFERENTIATION,

PROGNOSIS, AND TREATMENT.

§ 200. The Roatine Investigation of the disorders of the stomach consist
of three steps :

First : We must identify the patient's Leading Symptoms as being
referable to gastric disorder (see Part A.).

Secondly : Inquire as to the History, and especially whether the
illness came on acutely and recently, or whether, as is more usual, it came
on insidiously, and has run a chronic course. Much depends on the skill
and method with which the history is elicited. Inquire particularly as
to pain or discomfort and its relation to meals, and as to the other symp-
toms mentioned in Part A.

Thirdly : Proceed to the Physical Examination, and ascertain
whether there be any localised tenderness and pain, and whether any
tumour or other abnormality be present.

Classification of disorders of the stomach.

A. Acute Difeaies of the Stomach.

I. Acuto d3r8pepsia (bilious attack) : without tenderness . . • • § 201

II. Acuto gastritis : with tenderness . . . . . . • • § 202

B. Chronic Diseases of the Stomach.

(a) WxTHOUT TENDEBNSSS ON PBBSSURB : and pain less marked.

I. Chronic atonic dyspepsia . . . . . . • • ! 204

II. Chronic acid or irritable dyspepsia . . • • § 206

III. Gastralgia (gastric neuralgia) . . • • § 206

(b) With tenderness on pbsssxjbb : pain a marked feature.

IV. Simple ulcer of the stomach . . . . . . • • § 207

V. Cancer of the stomach . . . . . . • ■ § 208

VI. Chronic gastritis . . . . . . . . • • § 209

This classification, based on the presence or absence of tenderness, is not very

satisfactory, and each group will be found to contain many exceptions. It is, how-
ever, the least unsatisfactory of those clinical classifications possible at the present
time. The division of Chronic Dyspepsia into Atonic and Acid is also very un-
satisfactory (see footnote, p. 287).

If the patient's symptoms have come on gradually, and lasted a con-
siderable time, turn to Ghronic Disorders of the Stomach (§ 203).

If, on the other hand, his symptoms have commenced somewhat sud-
denly and recently, the case is probably one of the two Acute Disorders
of the Stomach : I. Acute Dyspepsia ; or, II. Acute Gastritis.

I. The pcUiefU — whose temperature is normal — complains of nausea,
gastric disoomfort, headache, and depression, which have come on sud-
denly ; and there is no marked epigastric tenderness. The disea.se is probably
Acute Dyspepsia.

§ 201. Acate Dyspepsia C' Bilious Attack ") consists of a sudden dis-
turbance of the digestion in a previously healthy person, such as occurs in
association with surfeit, high living or other errors in diet.

The Symptoms, which come on suddenly, are : (1) Pain, or a feeling of
oppression or distension in the epigastrium, occasionally accompanied by

286 THE STOMACH [ { 208

some tenderness on pressure, though the tenderness is never very marked.
(2) Nausea and vomiting very generally ensue (but not always). (3) Head-
ache, depression, anorexia, coated tongue, constipation, scanty urine
loaded with lithates. (4) The illness is sometimes preceded and accom-
panied by drowsiness, and not infrequently there is a history of previous
similar attacks.

The Diagnosis is not difficult, the only condition resembling it being
acute gastritis, in which the constitutional symptoms are more apparent,
the duration of the illness considerably longer, and the tenderness much
more marked. Irritant poisoning comes on much more suddenly with very
urgent vomiting (§ 191).

Etiology, — (1) Too large a meal, especially after previous fatigue.
(2) Errors in diet, such as excess of alcohol (which retards digestion),
ice, and many other articles which vary with the idiosyncrasy of the
individual.

Prognosis and TrecUment, — ^Acute dyspepsia of the kind here referred to
usually passes o£E in two or three days. (1) If pain be present, assist
vomiting by mild emetics, such as copious draughts of salt and water,
tickling the fauces, etc. Violent emetics aggravate the condition.
(2) Three grains of calomel, and milk diet for a day or two, generally
relieve the condition. (3) Bismuth and tonics may be given during
convalescence.

II. The patient complains of considerable pain or discomfort, and tender-
ness IN THE EPIGASTRIUM, toith nausca or vomiting, all of which have come
on somewhat suddenly. The disease is probably Acute Gastritis.

§ 202. Acate or Sab-acate GastritiB is relatively a much more serious
disorder than the foregoing. It consists of a sudden derangement of
digestion due to inflammation of the stomach. This condition is not so
much a catarrhal inflammation of the mucous membrane (excepting in
cases of irritant poisoning) as of the glands of the stomach.

Symptoms, — (1) Paid, intense and burning, or a feeling of distension
in the epigastrium, coming on directly after food, and accompanied by
tenderness on pressure. (2) Vomiting, not always immediately after a
meal, of undigested food, sometimes with streaks of blood. (3) Malaise,
anorexia, slight pyrexia, headache, depression, and other constitutional
symptoms may be present, attended sometimes by great prostration, thirst,
furred and coated tongue. (4) Diarrhoea may ensue after a day or two.

The Diagnosis may have to be made from acute dyspepsia (§ 201), and
from other causes of vomiting (§ 191).

Recovery generally takes place in about three to six days, the afiection
rarely lasting longer than eight or ten days. It may go on to chronic
gastritis. Death rarely takes place, excepting from irritant poisoning or
in cases of membranous gastritis.^

^ One case of this rare condition which recovered is recorded by Dr. Grunbaum in
the Lancd, August 2, 19C2.

S dOS ] ACUTE on SUB-ACUTE 0A8TBIT1S 287

EUdogy. — (1) In the majority of cases simple acute gastritis is caused
by errors in diet, or by decomposing meat — e.g,, tinned food containing
ptomaines -} an excessive quantity of normal food will cause it. (2) Irritant
poisons {e.g,, arsenic, antimony, phospjiorus, etc.). In long-continued
vomiting, without apparent cause, poisoning should be suspected, and the
vomited matters examined. (3) In some cases, gout and other constitu-
tional conditions predispose to or determine an attack.^ Heart, lung, and
liver disease are predisposing causes.

TreatmevU, — The indications are : (1) To remove any irritant that may
be present from the stomach. This can be done by promoting vomiting,
which is specially indicated if the epigastric pain continues, emplojong the
means mentioned in § 201. It may be desirable to give a purgative, such
as 3 grains of calomel, and a seidlitz powder in the morning. Hot fomenta-
tions or a mustard leaf to the epigastrium may relieve the pain. (2) The
second indication is rest to the stomach, which is gained by twelve or
twenty-four hours' abstinence from food, followed by milk in small quan-
tities. Later on, bismuth combined with opium is the best treatment.
The milk diet should be supplemented only very gradually.

CHRONIC DISORDERS OF THE STOMACH.

§ 208. The patient, whose temperature is normal, complains of *' Chronic
Indigestion,'* — ^i.e., pain or discomfort in some way connected with his food,
which has probably come on gradually , and may have lasted a long time.
There are Six Disorders, from any one of which he may be suffering, and
there may be Dilatation of the Stomach in addition.^

^ The products of the deoomposition of nitrogenous food-stufiEs, especially when
enclosed in hermetically sealed tins, occasionally give rise to the formation of toxic
substances. The effects are very severe. Symptoms of acute irritant poisoning
come on within a short time after the meal. The collapse is extreme, and death may
take place within a few hours.

^ 1 remember being called to see a medical man, about forty-five years of age, of
markedly gouty diathesis, who had previously had gouty manifestations. The
symptoms were thought at first to resemble those of enteric fever, the temperature
being 103^ to 105^ F. u>t several days ; but a brisk purge of calomel, salicylates, alkalies,
and milk diet, produced immediate improvement.

^ As I have already remarked, this classification is a very unsatisfactory one. As
more scientific methods of investigation, such as those foreshadowed in §§ 198 and 190,
come to be employed, we shall be able to classify cases which we now vaguely describe
as " Chbonio Dyspbpsia " into the following groups — ^groups which tall us wherein
the chief error of digestion lies :

I. DiSORDBBS OF SeOBBTION.

(a) Irritative States.— -{I) Hyperacidity (hyperchylia), hyperchlorhydria, ex-
cessive formation of HCI. (2) Supersecretion (gastrosuccorrhcsa, a
continuous flow of gastric juice : doubtful if this exists apart from
dilatation.

(6) Depressive States. — (1) Subacidity (h3rpochylia). (2) Inacidity (achylia
gastrica).
II. DisoBDEBS OF MoTiUTY, or Pcristalsis.

(a) Irritative States. — (1) Cramp of the cardia, pylorus, entire stomach.
(2) " Peristaltic imrest " of Kaussmaul. (3) Nervous eructations.
(4) Nervous vomiting.

(6) Depressive States. — (1) Insufficiency of the cardia or the pylorus. (2) Gas-
troplegia — atony or insufficiency of the entire gastric muscle, leading
to dilated stomach.

288 THE STOMACH [ S

(a) Fnnotioiial diseases of the stomach without tenderness.
I. Atonic Dyspepsia.
'> II. Acid or Irritable Dyspepsia.

III. Gastralgia.

(6) Organic diseases of the stomach with marked local tenderness and pain.

IV. Simple Ulcer of Stomach.
V. Cancer of Stomach.

VI. Chronic Gastritis,
(c) There are also many other disorders nnconnected with the stomach which may
give rise to symptoms -of chronic indigestion, among which the following may b^
mentioned : Phthisis (of which dyspepsia is often the earliest symptom), Appondlcitis,
Aneemia, Abdominal Tumour, Oeirdiac or Hepatic Disease, Renal or Uterine Disease^
various Nervous Disorders, and Pancreatic Disease (rare).

I. The fatient comflains q/' chronic indigestion, and the epigastric pain
or discomfort comes on soon after a meal. The disease is probably
Atonic Dyspepsia.

§ 204. Ghronic Dyspepsia may be defined as deranged digestion without
gross or inflammatory changes in the mucous membrane of the stomach.
It may be, and often is, attended by Atony or Dilatation, § 210. It
occurs in two generally accepted types.

I. Atonic Dyspepsia (the commoner form) is chronic indigestion due
to diminished digestive power of the stomach. It is sometimes due to a
deficiency of the acid in the gastric juice ; the pepsin is said by most to
remain normal in amount. It may also arise from defective motor power
of the stomach. In this disease the food may, in process of time, undergo
butyric acid fermentation, and then it is difficult to distinguish this form
of dyspepsia from II.

II. Acid or irritable Dyspepsia (§ 205 ; Synonym, hjrperchlorhydria)
is a chronic indigestion due to hypersecretion of acid in the gastric juice.

I. Atonic Dyspepsia is the commoner form of chronic dyspepsia. The
Symptoms are : (1) Pain or distress, usually in the epigastrium, coming on
immediately or very shortly after food. The pain may be in the back or
shoot up to the shoulders ; or there may be no definite pain, only a feeling
of weight or distension. It is unaccompanied by tenderness on pressure,
a feature which distinguishes it from gastritis and other organic conditions.
The pain is often relieved by eructations of wind. (2) Nausea and vomit-

III. Sensoby Disordebs.

(a) Irritative States. — (1) Hyperaesthesia. (2) Gastralgia. (3) BuL'mia and

polyphagia.

(b) Depressive States, — (1) Anorexia. (2) Acoria (? gastric •auaasthosia).

IV. Gastric Neurasthenia, and Gastroptosis.

These various conditions are, of course, mot with most frequently in combination,
just as paralysis and anaesthesia are met with in disease of the spinal cord. Thus atony
and dilatation inevitably lead to disordered secretion. But it is of the greatest
use for purposes of prognosis and treatment to know which particular element in the
digestive process is at fault. The subject, however, is extremely complex. For in-
stance, the gastric contents, in cases of Subacidity, may be highly acid from the
presence of latty acids, the products of decomposition. Those desirous of pursuing
this subject should consult Hemmeter's '* Diseases of the Stomach " (Blakiston,
Philadelphia), or the works of Mathieu (*^ Trait6 des Maladies de rfistomao et de
rintestin," Paris, 1901), Ewald, Roisshmann, Einhom and Rosenheim.

§ 204 ] CHRONIC DYSPEPSIA 289

ing are not frequent. (3) The appetite is usually diminished, but some-
times it is increased ; and the tongue is flabby and indented by the teeth.
(4) There are languor, depression, and general discomfort and drowsiness
after meals ; and there may be palpitation, dyspnoea, and other cardiac
symptoms. Thirst is not usual unless there be dilatation, and pyrexia
is absent. Urates in excess are constantly present in the urine. Some-
times erythema faciei and urticaria occur.

Etiology. — (1) Errors of diet ; (2) overwork, mental anxiety, and other
nervous derangements ; (3) imperfect mastication in previous years ;
(4) convalescence from acute diseases, annemia, and debility from any
cause (e.g,y phthisis), predispose. Dyspepsia is often the earliest sjonptom
met with in phthisis. (5) Various abdominal disorders — c.gr., pancreatic
or renal disease, appendicitis, enteroptosis, floating kidney, and abdominal
tumour, may for some time be evidenced only by symptoms resembling
atonic dyspepsia. (6) It may be part of organic disease of the stomach,
such as cancer.

Diagnosis. — The chief condition from which it has to be distinguished
is chronic gastritiSy in which there is usually tenderness on pressure ; and,
while stimulating articles of food (pickles, condiments, etc.), relieve the
pain of atonic dyspepsia, they tend to aggravate chronic gastritis (see also
Table XV.). Atonic dyspepsia may have to be differentiated from gastric
ulcer in the young, or oarhcer of the stomach in the middle-aged and old (q.v.).
The differentiation from acid dyspepsia is given under that disease (§ 205),
but it must be remembered that in atonic dyspepsia butyric acid fermenta-
tion is apt to take place, which is distinguishable from acid dyspepsia only
by an examination of the stomach contents.

Prognosis, — ^It is never fatal, but often renders life so wretched as to
unfit the sufferer for the duties of life. If met with early, treatment may
be very efficacious ; but, if untreated, it may go on to chronic gastritis
and dilatation of the stomach, and lead to general malnutrition (§ 194).

Treatment, — The indications are, to remedy the dietetic errors (see § 212) ;
to remove the cause ; and to stimulate the secretory and motor power of
the stomach. The teeth should be seen to. Alkalies and alkaline car-
bonates shortly before meals, combined with nux vomica, bitters, and
carminatives (Formula 66), stimulate the secretory powers of the stomach.
Some cases do best by taking their meals dry, so that the gastric juice
may be undiluted. Some find aid in pepsin, pancreatin, peptenzyme,
taka-diastase, or other artificial digestive. Tonics, especially strychnine,
are useful. Attention to the general health may succeed where stomachic
treatment alone fails. Abdominal massage, electricity and exercises to
promote muscular contraction are important curative measures. Rest
before and after meals is excellent in nervous cases. Various symptom^s
require treatment. For the flatulence 20 grains of sodium bicarbonate in
a cupful of hot water gives great relief. Peppermint, sp. chloroformi,
rhubarb, cinnamon, ginger, cardamoms, pepper, sodium sulphocarbolate,
charcoal, or Formula 50, are all useful. Acid eructations may be counteracted

290

THE STOMACH

[§«»

by antiseptics (carbolic acid, charcoal), or alkalies and bismuth. Bismuth,
hydrocyanic acid, and opium (with caution)^ may be used for pain. For
breathlessness, palpitation, and other cardiac symptoms, sal volatDe,
saline purgatives, and alkalies may be given. Compare also Treatment of
Chronic Gastritis (§ 209).

Table XV.

Tenderness
Vomiting

Thirst

Fever

Causes

Course

Chronic Dyspepsia.

Absent.

Not froquent, but relieves paio.

Varies ; not common.
Absent.

1. Dietetic errors.

2. General weakness of system

(anaemia after fevers,
etc.); or nervous exhaus-
tion, leading to deficient
secretion of gastrio juice,
or deficient motor activity
of stomach.

Liable to come on in attacks,
lasting a few days or weeks
at a time ; brought on by
slight causes.

Chronic Gastritis.

Present.

Frequent, especially in the
morning, of mucus ; no relief.

Usually marked.

Sometimes slight fever.

1. Dietetic errors, especially

alcoholic excesses.

2. Sequel to Heart or liver

Disease.

Does not come and go, but
progressively advances, and
goes on to dilatation of the
stomach.

II. The patient complains of chronic indigestion, biU the discomfort
does NOT COME ON SOON after a meal, and is relieved by food. The disease
is probably Acid Dyspepsia.

§ 205. Add Dyspepsia (Irritable Dyspepsia, Hyperchlorhydria, compare
§ 199) may be defined as chronic indigestion due to the hypersecretion of
hydrochloric acid in the stomach ; pepsin, according to most authorities,
remaining constant in amount. Opinions are divided as to whether this
is or is not a pure neurosis. Some regard it as a chronic glandular gastrUiSy
set up by local irritation of injudicious food, alcohol, or the decomposition
of retained food residues.

The Symptoms which distinguish this from Atonic Dyspepsia, which it
resembles in other respects, are : (1) Pain, severe, gnawing, intense,
burning, coming on one or two hours after food ; unattended by tenderness
on pressure ; and usually relieved by taking food. (2) Vomiting may occur,
or acid eructations, which may be so acrid as to make the throat sore ;
thirst, and generally an increased appetite. (3) The presence ofHCl in an
empty stomach, say, before breakfast, is the crucial test of hypersecretion.

^ De Quincey started his habit of ** opium eating ** for an intractable form of chronic
dyspepsia.

§{ 205, 206 ] ACID D TSPEP8IA—0ASTRAL0IA 291

When the secretion of acid is very excessive, attacks of vomiting of HCl
occur, lasting a few days. The patient may waken with pain in the
middle of the night. This condition is named gastro-aucchorcea.

Etiology, — (1) It is usually met with in young adults, or men in the
prime of life with strong constitutions. (2) Some maintain that this is
in reality a neurosis (vt(2e supra). (3) It may arise from excess in alcohol,
or highly spiced foods, or simply overloading of the stomach.

Diagnosis. — For the diagnosis from Chronic Gastritis, see § 209, and
Table XV., p. 290. Gastralgia may simulate acid dyspepsia ; but in the
latter the pain is relieved by alkalies, while in gastralgia it is not so relieved.
The examination of the stomach contents shows that in hyperchlorhydria
the proteids are more completely digested than in gastralgia. Many cases
of Duodenal ulcer have a history of hyperchlorhydria preceding the more
serious sjonptoms.

The Treatment is mainly dietetic (see § 212). A diet of proteids relieves

the condition, but if persisted in too long, this further stimulates the

secretion of HCl. Antacids, such as large doses of sodiimi bicarbonate

or creta preparata, may be given one to two hours after meals. Lozenges

constantly sucked, which induce a considerable amount of alkaline salivary

secretion, are useful, especially the bismuth, magnesia, and chalk lozenge

(B.P.). As a temporary measure, the acidity of the stomach may be

diluted by a copious draught of hot water, which relieves the pain and

acid eructations. A course of galvanism (see § 210), combined with the

proteid diet given below, is very efficacious.

In severe cases of Acid Dyspepsia the following diet may be tried for a few days
and relaxed gradually afterwards. The meals to consist of meat cakes (as much as
desired), and one or two slices of toast. Meat cakes are prepared by scraping the
fibres either of meat, fish, or poultry, with a blunt knife, leaving behind all the gristle
and sinews. Add a little salt, press into cakes, and fry lightly. Only 4 ounces of
fiuid to be drunk with each of the meals. As much fluid as desired may be taken,
but not nearer to a meal than one hour before or two hours afterwards. Osier recom-
mends strictly meat diet^ 3J ounces of meat, minced fine, taken raw, with two slico^s
of stale bread and 1 ounce of butter, with one glass of Apollinaris water, thrice daily.

III. The patient complains of sharp paroxysmal pain, having no DEPiNrrE
RELATION to the taking of food, and care/id investigation reveals no structural
disorder of the stomach. The case is probably one of Gastralgia.

§206. Gastralgia is ft gastric neuralgia, sometimes attended by a hypersesthesia
of the mucous membrane of the stomach, but always without structural changes or
alteration of secretion.

SymptotM. — (1) The pain is of a sharp or burning character in the epigastrium,
usually relieved by pressure. There is generally no tenderness, but if present, it is
usually more marked with a light than a heavy touch, thus differing from organic
disease. Sometimes it is unilateral. The pain may begin immediately after food, but
may come on either when the stomach is empty or when it is full. The irregularity

1 Herschell {Brit, Med. Joum., 1898, vol. ii., p. 1323) holds that cases of Hyper-
chlorhydria get worse on the administration of a largely or entirelv proteid diet, by the
encouragement thus given to the hypersecretion of acids. He therefore suggests the
substitution of a carbohydrate diet partially dextrinised by taka-diastase, and the
neutralisation of the hyperacidity by large doses of alkalies. Weak solutions of tannin
are also good.

292 THE STOMACH [ §§ 2M, 207

of its advent is one of its most oharaoteristic features. Sometimes it oomes on with the
first mouthful of food ; sometimes food relieves it ; sometimes it occurs in attacks
unrelated to food. Dieting gives no relief, for it may be worse after a milk diet than
after raw apples. (2) Vomiting and other symptoms are rare. (3) It generally occurs
in neurotic people, who have had neuralgia elsewhere. (4) It may accompany gastric
ulcer, or follow this and other diseases of the stomach.

Etiology. — (I) Gastralgia may come on at any age, and in either sex. (2) Some con-
stitutional state, such as hysteria, neurasthenia, ansemia, ague, alcoholism, or gout,
is usually present at the same time. (3) In tabes dorsalis, gastralgia is the most
frequent fcrm of crisis {crise gtutrique).

Diagnosis. — ^ThoEC cases of gastralgia in which food relieves the pain have to be
diagnosed from Hyperchlorhydri€L The diagnosis in such cases is efiFectod, first, by
administering alkalies an hour or so after meals ; they relieve the pain of hyper-
chlorhydria, but not that of gastralgia. Secondly, acid eructations are a prominent
feature of hyperchlorhydria, but not of gastralgia. Thirdly, excess of hydrochloric
acid is found on examining the stomach contents in hyperchlorhydria. Ulcer of the
stomach has a more limited area of tenderness on pressure ; the pain comes on immedi-
ately after food, and is relieved by vomiting. Increased HCl is found on examination
of the vomited matter. Cancer of the stomach is very difficult to diagnose from gas-
tralgia before tumour or hsmatemesis supervenes, but in this disease the pain is
usually more constant. Biliary colic is usually associated with jaundice.

Treatment — (1) Treatment directed to the constitutional condition generally relieves
the gastric trouble sooner or later. (2) Warmth to the epigastrium, opium (with
caution), nitrate of silver internally (^ grain), and arsenic in small and frequent doses.
For the vomiting give hydrocyanic acid, bromides, and liq. arsonioalis (nii. in a drachm
of water every half an hour).

Group B. If the patient complains o Chronic Indigestion, attended by
pain and marked tenderness on pressure^ we are justified in suspecting the
presence of organic disease of the stomach— viz., IV. Simple Ulcer ;
V. Cancer ; or VI. Chronic Gastritis.

IV. T7ie patient is an ancemic young woman, and complains of severe
PAIN, produced by FOOD and relieved by vomiting, Ae vomit some-
times containing a large quantity of Mood. The disease is Simple Ulcer
OF the Stomach.

§ 207. Simple (i.e., non-malignant) Ulcer of the stomach, is so called in
distinction from cancerous ulceration. The ulcer is usually single, and
generally situated on the posterior wall, near the pylorus on the lesser
curvature. In this disease there are, in addition to symptoms of chronic
dyspepsia, three very characteristic features :

(1) Pain of an intense boring character usually limited to one spot,
(2) aggravated by food, and accompanied by tenderness. A small, very
tender area, pressure on which even by the bed-clothes cannot be borne,
is sometimes present, and is very characteristic. It is usually situated
in the epigastrium. (3) The pain is relieved by vomiting, which comes on
very shortly after food. The vomited matter contains an excess of hydro-
chloric acid. (4) HsematemesiB, which may be profuse, comes on sud-
denly from time to time. (5) The appetite is usually normal or increased,
but the patient avoids food because of the pain it produces. There is
generally constipation. In acute cases there may be no symptoms until
profuse haemorrhage or perforation suddenly occurs.

The Diagnosis is not difficult if pain, an area of tenderness, and haema-

!807]

SIMPLE VLCER

293

temesis be present. The last, which was thought to be the modi charac-
teristic symptom, is now known to be very profuse in gastrostaxis (§ 192).
When one or other is absent, the disease has to be diagnosed from gastralgia
(§ 206) ; from cancer and chronic gastritis, see Table XVI., below, or from
the other causes of Hspmatemesis (§ 192).

Table XVI.

Vomiting

Hasmaiemesis

Tutnoiur

Age ..

Course

SiMpLB Ulceb. Malignant Disease. Chbonio Gastbitis.

Frequent ; di-
rectly after food ;
relieves pain.

Very large quan-
tity every few days.

Occasional but ; A continuous ooz-
profuse ; therefore | ing; therefore
bright red. i " ooflfee - ground "

in character.

Present, though
may not be palpable;
secondary deposits
may be recognisable
in Uver, peritoneum,
glands, etc., later on.

None.

Morning vomiting
of mucus.

Rare ; and only
streaks, unless in the
venous congestion
due to heart disease.

None.

Young women,
twenty to thirty.

Indefinite ; re-
lapses occur.

Usually men over Any age.

forty. !

Fatal in one to Indefinite ; may

two years. go on to Dilatation.

Etiology. — The disease is much more common in females, chiefly between
the ages of twenty and thirty, and especially in association with ansemia
and chlorosis. Some cases have been traced to embolism from heart disease.
Some say it is more common among the poorer classes ; it certainly is
often met with among domestic servants. Former statistics are mis-
leading, as recent surgery has revealed the fact that many cases of hsema-
temesis supposed to be due to gastric ulcer were due to oozing without
ulceration (§ 192). In men ulceration occurs most often between forty
and sixty.

Prognosis, — The mortality is equal in the sexes, as the disease is frequently
cured in young women. The prognosis is usually favourable if the con-
dition is treated early, but there is a great tendency to relapse. If un-
treated, perforation into the peritoneal cavity may cause death (see § 169).
When a more favourable course is followed, the resulting cicatrisation may
lead to distortion or stricture of the stomach or pylorus. Stricture of
the pylorus leads to dilatation of the stomach. Stricture of the stomach

294 THE STOMACH [ § W7

leads to the " hour-glass " contraction — i.e., the stomach is divided into
a cardiac and a pyloric cavity. Adhesions to surrounding viscera, sub-
phrenic abscesses, or abscess in other situations may result. Death occa-
sionally results from haemorrhage. The amount of the bleeding is no
measure of the size or depth of the ulcer.

Treatment, — In all but the mildest cases the patient must rest in bed.
If there has been recent hsematemesis or intractable vomiting, no food
should be allowed by the mouth, but ice may be given to suck. Alimenta-
tion must, in such cases, be solely fer rectum, A suitable enema b as
follows : Pancreatic solution, 1 drachm ; bicarbonate of soda, 10 grains ;
yolk of one egg ; beef-tea, \ ounce ; and milk, up to 4 ounces. (Other
enemata are found in Formula 14.) These should be given hourly. The
bowel must be washed out with saline at least once a day, and as much
saline as possible should be retained, for by this means the thirst is relieved.
After from three to ten days, a very gradual return must be made to
ordinary diet, beginning with peptonised or citrated milk, then custard
and bread and milk, then bread and butter, eggs, fish, and chicken, and
finally butcher's meat. The treatment extends over about three months,
most of which should be spent in bed. In less severe cases dieting may
start with milk, either peptonised or citrated. Lenhartz introduced a
modification of this treatment based on the theory that the subnutrition
induced by starvation and rectal feeding was prejudicial to the healing
of the ulcer, and that gastric juice in a fasting stomach was irritating to
the ulcer. The food given must be such as will neutralise the stomach
acid, will excite little secretion, and, thirdly, of a bulk which will not
distend the organ. Absolute rest in bed is essential for four weeks, and
the ice-bag is kept over the stomach during the first fortnight. The diet
consists of eggs beaten up with sugar, and iced, and of milk, taken in
small quantities, frequently during the day. On the first day one egg
and 7 to 10 ounces of milk are given. Every day one egg and 3 J ounces
of milk are added till eight eggs are taken daily. Baw minced meat
(1 ounce) is added about the fourth to the eighth day ; then boiled rice and
soft bread. Gradually meat and pounded fish are substituted for the eggs,
and by the end of the fourth week ordinary diet is taken. Large doses
of bismuth are given at the beginning ; and after the first week iron. No
aperients are taken during the first week.

The treatment of the haemorrhage is given under Haematemesis (§ 192).
In the intervals between the acute attacks alkaline carbonates, bismuth,
small doses of tannin and many other of the remedies used in gastritis
(q.v.) have been recommended. For the pain, give hydrocyanic acid,
opium, bismuth, and alkalies. In very chronic cases nitrate of silver
may be tried. To regulate the bowels, the best form of aperient, if enemata
fail, is a drachm of Carlsbad salts in 3 or 4 ounces of water (120° F.) taken
every fifteen minutes in four doses up to half an hour before breakfast.

The indications for operation in gastric ulcer are (i.) perforation ; (ii.) for
frequently I'ecurring obstinate cases ; and (iii.) for haematemesis. For

f§ 807, 208 ] CANCER OF TBE SfOMACEl 296

perforation, immediate operation is imperative. For (iii.) surgical measures
should not be lightly employed, since recurring and severe hfiBmatemesis
may be unassociated with ulceration (see Gastrostaxis, § 192). Moreover,
recurrence is by no means uncommon, after excision of the ulcer or gastro-
enterostomy has been performed. If, in spite of adequate treatment,
such as is detailed above, the pain, vomiting, or bleeding prove intractable,
operation must be considered.

Duodenal Ulcer occurs mostly in males between eighteen and forty.
The symptoms may be very obscure, or (1) symptoms of hyperchlorhydria
may be present (§ 205), with intense pain (the so-called " hunger pain "),
relieved by taking food. The attacks of pain may last for weeks, and
during the intervals the patient feels well and gains weight. (2) There is
tenderness just above and to the right of the umbilicus. (3) There may
be sudden intestinal haemorrhage, evidenced by melsBna, preceded or
accompanied by hsematemesis, and the attacks of gastric pain may be
€uxx>mpanied by haemorrhage. The stomach contents and faeces should
be examined for traces of occult blood, an important point in the diagnosis
from simple hyperchlorhydria. As in gastric ulcer, the first symptoms
may be those of perforation. The treatment is usually surgical.

v. The patient, who is in middle or advanced life, presents more cachexia*
than could be accounted for by dyspepsia, and vomits from time to time
" coFFEE-aROUND " MATERIAL. There is probably Malignant Disease
OF the Stomach.

§208. Cancer of the Stomach. — ^The stomach is a frequent site for
primary cancer ; it has been foimd in as many as 1 per cent, of all post-
mortems. The word '* cancer " is associated in our minds with a tumour,
but in two-thirds (two-fifths Hemmeter) of the cases of cancer of the
stomach there is no tumoiir, but a scirrhus infiltration of the pylorus,
which produces obstruction of that orifice and leads to Dilatation (§ 210).
The clinical history, which rarely extends beyond one or two years, may
be described in three stages. In the first stage we find the symptoms
of chronic gastritis (§ 209) combined with marked cachexia. In the
second stage, combined with these are acute pain (generally), vomiting,
and haematemesis of a very characteristic kind. In the third stage, beside
the preceding, we get either dilatation of the stomach, or tumour, or both.
In many cases, however, there are no symptoms referable to the stomach,
and the diagnosb is only made in the deadhouse.

Symptoms. — (1) Loss of appetite, soon followed by cachexia, occurs early,
and is very marked ; and these symptoms in a patient of 40 or upwards
should always make us suspect the condition. The sallowness of the skin
may almost pardonably be mistaken for pernicious anaemia, or even
jaundice. (2) The pain is situated in the epigastric region or back, radiates
in different directions, and is usually accompanied by tenderness. It is
continuous, sometimes increased by food, but sometimes independent of the
taking of food. (3) Vomiting is a fairly constant sign. (Generally it takes

296 fHE STOMAOn [ $ SOd

place some time after the ingestion of food, the interval depending upon
the position of the lesion ; thus, if at the cardiac end, the interval is short ;
if at the pylorus, it may be hours after taking food. Sometimes the
vomiting occurs every two or three days. An examination of the vomited
matter shows diminution or absence of hydrochloric acid and the presence
of lactic acid. (4) HcBtnatemesis is generaUy present sooner or later. The
bleeding is small in quantity, but occurs frequently, and therefore the
blood is partly digested, and gives rise to a characteristic brown appearance,
as of coffee-grounds, (5) Dilatation of the stomach is sure to ensue if the
pylorus is involved (§ 210). SarcinaB (Fig. 61) and other evidences of
decomposition may be present, and sometimes cancer cells. (6) Tumour
is much less rarely met with than one would expect. Transmitted aortic
pulsation, and a little fulness or rigidity of the upper end of the right
rectus, may be present without a palpable tumour. When cancer is
deposited in the pylorus, it may cause adhesions which prevent the tumour
from coming forward. The great majority of gastric timiours come for-
ward to the left of the middle line. It is usually stated that w^hereas
hepatic tumours move, gastric tumours do not generally move with
respiration ; but this feature, as Hemmeter points out (loc, cU.), has many
exceptions. One of greater importance is their alternate appearance and
disappearance. At first they are extremely mobile, but later on they
become fixed owing to adhesions. This is also the reason why perforation
is rare. Distension of the stomach by copious draughts of water may
help us in the physical examination.

Etiology, — (1) Cancer of the stomach is more frequent in men. (2) It is
rarely met with under forty, although I have seen one case of twenty-
eight, another of thirty, and several between thirty and forty years.^
(3) Simple ulcer and chronic gastritis appear to predispose. (4) Hereditary
influence often exists.

Diagnosis, — ^Anorexia and cachexia are the only constant symptoms.
"When the typical vomiting is absent, the real nature of the case may be
readily overlooked.

The chemical examination of a tost-moal is of groat value. According to Willcox,
in involvement of the cardiac end, the total acidity ia low, and froe hydrochloric acid
is never present. Active hydrochloric acid is present in very small amount — about
0*02 per cent. Organic acid is generally present, abo traces of mucin, but little or no
albuminose or peptone. In involvement of the pyloric end the total acidity is sub-
normal, but still may be considerable (from 0*05 to 0*1 per cent.). Free hydrochloric
acid is absent ; active hydrochloric acid may be present in fair amount, but scarcely
ever exceeds 0*1 per cent. Organic acids are present generally. Mucin, albumin,
and large amounts of peptone are found.

If emaciation be rapid, and gastric symptoms resist treatment, cancer

should be strongly suspected. Dyspepsia and chronic gastritis have pain

directly related to food ; for these, and Simple ulcer of the stomach, see

Table XVI., p. 293. For Simple pyloric stricture, see Dilatation. Tumour

^ My experience of this disease at the Paddinston Infirmary was perhaps unusually
large. The case, aged twenty-eight, is recorded in the Clintcal Journal, about 1888
or 1889.

§S 808, 80d ] CANC^k OP THE STOMACH 297

of the fylorus or stomach has to be diagnosed from tumour in the neigh-
bouring regions (§ 188). Addison^s disease and other cachectic conditions
must be excluded (Chapter XVI.). Pernicious ancemia is sometimes strongly
suggested by the colour of the patient, but in this disease there is not a
corresponding amount of emaciation, and the blood-picture is different.

The Prognosis is very grave. The duration is rarely longer than six to
eighteen months after the first definite symptoms appear. Death is the
invariable result unless surgical measures are adopted early. The symp-
toms upon which one relies most in the diagnosis in these cases, anorexia
and emaciation, have always appeared to me to be those which also best
measure the longevity of the patient. Death generally takes place by
inanition, but almost as often it occurs suddenly by the involvement of
important structures, and it would be unwise to assume that because the
patient does not waste he will not die soon.

Treatment. — The indications are to support the strength and relieve
the symptoms. The former may be accomplished by easily digestible or
predigested food (§ 212). For the latter consult § 210, Dilatation. For
the flatulence and pain, creosote and opium, or morphia hypodermically.
Condurango, 30 grains four times a day, was said to be a specific in cancer
of the stomach, and papain has also been recommended. Pylorec-
tomy and gastro-enterostomy are now successfully performed. X rays
often diminish the pain, and possibly retard the growth of the neoplasm.
Kadium also should be tried when possible.

VI. In addition to other symptoms of chronic indigestion, tJie patient
who has beeUj perhaps, the subject of chronic alcoholism, or cardio-pulmonary
disease — voMirs mucus in the morning, sometimes streaked mth blood.
The disease is probably Chronic Gastrftis.

§ 209. Ghronic Gastritis may be defined as a form of chronic indigestion
due to parenchymatous inflammation (t.e., chiefly of the glands) of the
stomach.

Symptoms, — (1) Pain coming on shortly after food, usually of a dull
character, and attended by tenderness on pressure. (2) Mucous vomiting
in the morning, or, indeed, mucus found in the stomach contents at any
time, is a very characteristic feature of chronic gastritis. Streaks of blood are
occasionally present. (3) Thirst is also a prominent feature. (4) A slight
degree of pjnrexia is sometimes present. (5) The appetite is usually good,
but the first few mouthfuls of food satisfy. (6) Flatulence, and other
symptoms, as in atonic dyspepsia (§ 204). (7) General symptoms are in-
variably present — depression, nervousness, anaemia, loss of flesh, sallow-
ness, and other symptoms referable to the causes of the condition (see
below). Chronic gastritis may constitute an early phase of cancer — ^a
fact which it is well to remember ; the loss of appetite is then very marked.

Diagnosis, — Atonic dyspepsia, which has no tenderness on pressure, and
no mucous vomiting in the morning, and cancer are differentiated in
Table XVI., p. 293.

298 THE STOMACH [ H 209, 210

Etiology, — (1) Persistent dietetic errors, especially alcoholic excesses,
(2) Venous congestion, arising either from cirrhosis of the liver, or from
heart disease. (3) It may be a sequence of repeated attacks of acute
gastritis. (4) Constitutional debility, such as that in Bright's disease,
gout, etc., may predispose ; and so also may (5) Local causes, such as
cancer, ulcer, and stricture of the pylorus.

The Prognosis depends a good deal on the cause and the duration of
the symptoms. The case is more grave when due to irremovable venous
obstruction. If the disease remain long untreated, the stomach becomes
dilated, the walls fibrous, and the glands impaired or destroyed. There
are three stages : First, simple congestion, in which the pepsin is normal
in amoimt but the hydrochloric acid is diminished, and lactic and fatty acids
are foimd. The second stage is one of mucous ccUarrh, in which there is a
large secretion of mucus, hydrochloric acid is almost completely absent,
and very little pepsin is present. In the third stage there is atrophy of
the mucous membrane. In this stage both hydrochloric acid and pepsin
are absent.

Treatment. — (1) Here again a correct diet is the most important indica-
tion (§ 212). Give small quantities of dry food at long intervals (six or
more hours). Alcohol and condiments should be stopped, and smoking
must be interdicted. (2) The medicinal indications in the first stage and
in mild cases are (i.) to promote the flow of gastric juice and stimidate the
stomach power by bitters, gentian, quassia, nux vomica, and carmina-
tives ; (ii.) stimulate the secretion of the stomach by alkalies and bitters
given before meals, or aid the defective secretion by giving hydrochloric
acid after meals. (3) Symptomatic treatment : For the pain, bismuth,
magnesium carbonate, and opium ; for fermentation and acidity, alkalies,
two or three hours after a meal. Mucous vomiting is relieved by draughts
of hot water, with alkalies, before breakfast. If the appetite is too keen,
give bismuth and magnesium carbonate ; in this condition bitters are
harmful, as they excite the nerve-endings in the stomach. In the later
stages the indications are (i.) to replace the absent gastric secretion,
which is done by giving pepsin, pancreatin, hydrochloric acid, and pre-
digested foods ; (ii.) to prevent fermentation, give alkalies and antiseptics
along with meals, such as creosote, carbolic acid, and sulphocarbolate of
sodium.

(c) The patient presents symptoms of chronic indigestion, and on
physical examination there is splashing, or the area of the stomach
RESONANCE is increased, or there are food residues before breakfast. The
disease is probably Gastric Atony or Dilatation.

§ 210. Gastric Atony and Dilatation of the Stomach are conditions which
may accompany or succeed many of the preceding disorders. Gastric
Atony, the importance of which has been previously referred to (§ 198)
is insufficiency of the power of the stomach to empty itself, independently
of pyloric obstruction.

§ 210 ] QA8TRIC ATON Y AND DILATATION 299

(a) Gastric Atony (Motor InsufiSciency) may, it appears, exist in
three stages or degrees, (a) In simple loss of tonicity the stomach is able
to empty itself, but there is delay, and splashing can be elicited during the
period of digestion, which is prolonged. Many of these cases are latent,
and exhibit no symptoms for a considerable time. (P) Stagnation myas-
thenia gastrica, where the stomach cannot empty itself before the next
meal, though it does so during the night, (y) Retention myasthenia gastrica,
or true dilatation, in which the stomach cannot empty itself during the
night, and at all times contains food residues, even when examined by
the tube before breakfast. The symptoms of gastric atony are (1) pro-
longed lassitude after meals, with other symptoms of delayed digestion
and atonic or irritable dyspepsia (§ 204) ; (2) " splashing " several hours
after a meal (§ 197) ; and (3) on percussion or ausculto-percussion some
hours after a meal there will be an enlarged area of resonance, particularly
to the left of the middle line. This test may be aided by the patient
taking a draught of some aerated water, or a solution of sodium bicarbonate,
53 grains, followed by tartaric acid, 45 grains, in solution (which generates
at the body temperature just 1 litre of COg), or by inflation of the stomach
by a suitable apparatus. (4) The method mentioned in § 198, with the
bismuth meal and X-ray examination, affords a ready means of detecting
and measuring gastric atony.^

(6) Gastric Dilatation may be a consequence of gastric atony, or due
to pyloric obstruction. Its symptoms are (1) the same as those of gastric
atony in a more marked degree ; and (2) definite food residues found in the
stomach before breakfast, without which one would not be justified in
believing that a condition of* permanent dilatation existed. In all cases
of suspected dilatation the stomach should be examined by the tube in
the early morning, after a long fast. This also gives an important clue
to the substances in which digestion is defective. (3) Visible peristaltic
movements in the epigastric region may sometimes be seen when the
dilatation is due to pyloric obstruction. (4) One of the most characteristic
sjTnptoms of dilated stomach due to pyloric obstruction is the vomiting,
at intervals of two or three days or more, of large quantities of acid frothy
material, containing sarcinae (Fig. 61), on which a scum forms on standing.
Vomiting may be altogether absent, but if it is present and has these
characteristics we may be satisfied that there is dilatation. (5) The remain-
ing symptoms vary with the cause, of which there will be a history, or
evidence at the t'mie (injra), (6) Autotoxic symptoms invariably ensue —
marked lassitude, and various other functional nerve symptoms ; sometimes
urticaria and other eruptions. Tetany is one of the sequelae in severe
cases.

Etiology. — ^Dilatation of the stomach may be a consequence of one of
two conditions — atony of the muscular tissue (a and g below), or

PYLORIC obstruction.

^ See also an important discussion on Qastrio Atony at tlie Brit. Med. Assoc., 1902 ,
the Lancet, August 2, 1902.

300 TBB SfOMACU [ J 210

(a) Gastric Atony may occur after prolonged overfeeding, " bolting "
the food in early life, alcoholism, chronic dyspepsia (and its causes), or
chronic gastritis. Rheumatism, enteric, influenza, and other acute in-
fections have also been mentioned ; and there is no doubt that states of
general debility and anaemia, such as are associated with phthisis (especially
when combined with excessive feeding) and neurasthenic conditions
markedly predispose.

(6) Obstruction due to a growth of scirrhus cancer at the pylorus is one
of the commonest causes, and it may produce the most pronounced dilata-
tion (§ 208).

(c) Pyloric obstruction may also occur from the cicatrisation of a simple
ulcer of the stomach. The age and sex of the patient and her previous
history are characteristic (§ 207).

(d) Pyloric obstruction may be due to pressure from without — e,g,y
enlarged glands in the fissure of the liver, etc.

(e) Pylorio obstruction due to a band of adhesion is rare, and difficult to diagnos.e
It can only be recognised by the exclusion of other causes, and the histoiy of inflam«
mation of the peritoneum.

(/) Congenital hypertrophic stenosis, see § 191.

{g) Acute dilatation of the stomach is a rare variety that is often difficult to recog-
nise. It may come on more or less suddenly in early life, or in states of general
weakness, with symptoms of collapse, resembling intestinal obstruction. It is a
serious condition.

The Diagnosis of a markedly dilated stomach is not difficult ; the chief
question is as to its cause. But the diagnosis of simple atony or myasthenia
is always problematical imless the stomach tube or chemical tests be
employed*

Prognosis, — ^It is always a troublesome malady, especially in cases of
incurable stricture of the pylorus. Even in atonic dilatation the cure is
very tedious, but the prognosis is ultimately good if the disease be diagnosed
early, and the cause removable. Malignant stricture is the commonest
cause of pyloric obstruction, and unless dealt with surgically is fatal.

Treatment. — The indications are : (1) To keep the stomach as empty as
possible. This may be done by diet No. II., § 212, or by washing out the
stomach.^ It should be done last thing every night. According to Dr.
Herschell, it is best to use plain water. Give concentrated or predigested
foods with very little fluid. Give few carbohydrates, and never at the
same meal as animal foods. Carlsbad salts carry ofi much of the residue
lying in the stomach when taken every half-hour in the early morning
imtil purging ensues (F. 46 or 51). (2) Give tone to the muscular wall
by electricity. (3) Promote digestion (vide Chronic Dyspepsia). (4) To
prevent fermentation, the symptoms of which are very troublesome,
carbolic acid (1 to 3 minims), thymol (5 grains) or sodium sulphocarbolate
(20 grains), given preferably in a timiblor of water between meals. After
lavage, creosote or calomel (^ grain t. d.) may be given with advantage.

^ Method, see § 199. Sometimes Turok's double tube is used, the efferent being wider
than the afferent tube, to prevent overdistension.

§2100-212] DIETARIES AND INVALID FOODS 301

Surgical treatment may be needed in cases due to pyloric obstruction,
and pylorectomy and gastro-enterostomy have been successfully performed.

Electricity is of great use in dilated stomach, not only for giving tone to the muscular
wall, but also for promoting digestion and general nutrition. Faradism may be used,
preferably with Einhom's intragastric electrode, but the author has obtained very
good results by moans of galvanism applied externally.

§ 210a. Kenrasthenio Dyipepsia (synonym: Gastric Neurasthenia^) is probably a
form of gastric atony. We have seen that the nervous system may be seriously
deranged as a consequence of gastric disorder, and the opinion is rapidly gaining
ground that the motor, and probably the secretory, powers of the stomach may fail
as a consequence of functional nervous disorder. The symptoms do not differ materi-
ally from Chronic Atonic Dyspepsia due to other causes, as far as our present knowledge
goes. Such cases must be recognised by the circumstances under which they occur.
Electricity is especially useful in their treatment.

§ 211. Oastroptosis (Dropping of the Stomach ; Enteroptosis) is a condition in
which the stomach has dropped from its position. The symptoms and signs are apt
to be confused with Gastric Dilatation. The lessor curvaturo may be obvious on
inspection or palpation, but it is clearly detected by the method of inflation, or by
X rays after a bismuth meal. An aggravated state of neurasthenia is usually asso-
ciated with the condition.

Dietaries and Invalid Foods.

§ 212. Less food is required in old age than in youth, and with a seden-
tary life than with an active or outdoor one. For a person in health
three meals a day are usually sufficient ; but when a man is unable, from
illness, to take more than a very small quantity at a time, he may require
to take more frequent meals. Dietetic errors are a fruitful source of
dyspepsia and gastritis. Too frequent meab, habitual over-feeding, and
irregularity of the meals will in time derange any stomach. Deficiency of
food, and long restriction to the same kind of food, induce dyspepsia by
affording no stimulus to excite the secretions ; and in this connection it is
well to remember that a frequent cause of failure on the part of the
physician to cure dyspepsia is his disregard of this latter fact. Carbo-
hydrates, especially potatoes and new bread, are particularly harmful for
atonic flatulent dyspepsia. In anaemic cases with atonic dyspepsia starchy
foods do not afford sufficient stimulus for the gastric functions ; proteida
such as tender and underdone meat are more readily digested. It is often
a good rule to start treatment by cutting down the amount rather than by
entirely prohibiting the use of certain articles of diet. Too frequent a use
of condiments, spices, and tea, and of alcohol especially, lead to chronic
gastritis ; while dyspepsia is induced by imperfect mastication, bolting of
meals, too much fluid with meals, hard mental or physical work immediately
after eating, too cold or too hot food, or food which is badly prepared.
Excess of tobacco-smoking is certainly a cause of dyspepsia. Greasy and
fried foods are bad in dyspepsia, because the gastric juice cannot penetrate
the coating of fat. " Well-made " pastry and other so-called rich carbo-

^ The terms " gastric neurasthenia " and " dyspeptic neurasthenia " should be
reserved for Neurasthenia of Gastric origin, as explained in the author's Clinical
Lectures on Neurasthenia, fourth edition, 1908.

302 THE STOMACH [ § 218

hydrate foods are a source of dyspepsia only when taken at the same meal
as proteid food. Hyperchlorhydria is induced by constant proteid over-
feeding.

Without appropriate dietetic rules our best efforts may fail, especially in the treat-
ment of gastro-intestinal disorders, and other diseases which depend on the proper
elaboration and assimilation of food. A few specimen dietaries will therefore be
given, culled from various authors, or my own experience. These will serve as a basis
for any number of other dietaries.

I. The following table is given as a guide to aid in the drawing up of a diet for
mild cases of atonic dyspeptia or chronic gaitritis : Breakfast. — Boiled sole, whiting,
or flounder ; or a slice of crisp fried bacon or a soft-boiled egg ; a slice of dry toast with a
little butter, or of bread (not new) and butter. Beverage, — One cup of cocoa or of milk
and water, sipped after eating. Luncheon, — Chicken or game, with bread, and a
little tender, well-boiled vegetable, such as spinach, vegetable marrow, or young
French beans. Beverage, — Half a tumbler of water sipped after eating. Afternoon
Tea, — ^A cup of cocoa or of weak tea with milk, and a slice of brown bread and butter.
Dinn^ (two courses only). — ^Fish of the kinds allowed for breakfast, without potatoes.
For sweets and desert, a plain biscuit will suffice. Or a slice of any tender meat,
such as saddle or loin of mutton, or the thick part of an underdone chop with crumbled
stale bread ; custard, junket or jelly, or a little well-stewed fruit. Beverage, — Half a
tumbler of water, with from one to two tablespoonfuls of spirit if desired.

Condiments and stimulants are good in atonic dyspepsia, but must be avoided in
chronic gastritis, as tending to cause further irritation of the mucous membrane.
The patient should abstain from salted and cured meats,^ tinned foods, sweets, pastry,
raw vegetables, cheese.

II. The ** Salisbury ** diet consists essentially of the administration of nitrogenous
food only, the meals being taken almost without fluid, but a quantity of hot water
being taken between meals. There are several principles involved in this treatment.
In the first place, it is obviously a marked change from a person's ordinary diet, and
the principle of " relativity " is introduced. Secondly, the solid food administered
is in a highly concentrated form, and gives the stomach a considerable rest from its
functions while the diet is administered. Thirdly, there is the elimination of the
farinaceous and bulky substances which readily decompose and produce flatulence and
kindred troubles. Fourthly, by reason of the dryness and small bulk of the food, a
dilated or atonic stomach is enabled to resume its normal dimensions, much in the
same way as bleeding will relieve a distended heart. The details of the diet are com-
paratively simple. One pound (1 lb.) of lean butcher's meat, chopped or scraped
very fine, and so as to rid it of its white fibrous tissue, and lightly cooked, is taken
per diem, divided into four or more meals. Occasionally a little well-toasted or twice
baked (Zweibach) bread is allowed also. For a change, \ pound of fish may be sub-
stituted for an equal quantity of meat. The meals are taken quite dry, or 2 ounces
of fluid only ; but two hours later ^ to 2 pints of hot water are sipped.

III. Diet for Obesity (§ 18). — Breakfast, — Fish, bacon, beef, or mutton (6 ounces) ;
one breakfastcupful of tea or coffee without milk or sugar, and one small hard biscuit,
or one ounce of dry toast. Dinner. — Fresh white fish, beef, mutton, lamb, game, or
poultry (6 ounces) ; green vegetables ; one slice of dry toast ; cooked fruit sweetened
with saxin. Tea. — A cup of tea without milk or sugar ; a biscuit or a rusk ; 2 or 3
ounces of cooked fruit. Supper, — Meatorfi8h(about 3 ounces) with toast. If desired,
a glass or two of sherry or claret may be taken.

IV. Dietary for Diabetes Mellitns (strict).

AUow — Butcher's meat, poultry, game, and fish ; cheese, eggs, butter, cream, fat
and oil ; broths, soups, and jellies made without meal and sugar ; green vegetables,
cabbage, spinach, broccoli, Brussels sprouts, green lettuce, spring onions, water-cress,
mustard-and-cress, mushrooms ; cream custard (not milk). For bread is substituted

^ Niemeyer, however, reports the cases of a few patients who voluntarily at times
restricted themselves to a diet'^of salted and preserved meats whenever dyspeptic
symptoms arose. Probably the success in these cases was due to the fact that such
meats are not readiiy decomposed.

! 212 1 DIET ABIES AND INVALID FOODS 303

bran-oake, gluten bread (and meal), almond meal rusks and biscuits ; dry sherry,
claret, light bitter ale, brandy, and whisky in small quantities ; tea, coffee (without
sugar), chocolate (made with gluten meal), soda-water, bitartrate of potash water.

Forbid — All saccharine and farinaceous foods, bread, potatoes, rice, tapioca, sago,
arrowroot, macaroni, etc. ; blanched vegetables such as celery, white stalks of lettuces,
etc. ; turnips, carrots, parsnips, beans, and peas ; crabs and lobsters. Liver contains
much sugar-forming substances, therefore oysters, cockles, and mussels, which contain
relatively large livers, are forbidden. All sweet fruits, as apples, pears, plums, goose-
berries, currants, grapes, oranges, etc. ; port, and all sweet wines ; sweet ales and
porter ; rum and sweetened gin.

V. Diet in Chronic Blight's Diieaie (Sir Andrew Clark, modified). — Breakfast. — A
flate of oatmeal, whole wheaten meal, or hominy porridge, with cream or good milk ;
bread or toast and butter ; cocoa, tea, or coffee, with plenty of milk added. Or a
slice of well-cooked bacon, fish, or fat bam, may take the place of porridge. Luncheon.
— ^A little fish, with some melted butter, mashed potato, and green vegetable, biscuit
or bread and butter. Or a basin of vegetable soup, a bit of cheese, breiwi, butter,
and salad. Or a milk pudding, with stewed fruit and cream, bread and butter. After^
noon Tea, — A cup of tea with milk, a slice of thin bread and butter, or rusk. Dinner. —
Soup, pur6e of potato, chicken or rabbit, mashed potato, green vegetables, plain or
milk pudding, with stewed fruit. Or boiled fish, butter sauce, a plain entree with
vegetables, milk pudding or shape, stewed fruit or blanc-mange, biscuit or bread
and butter, a glass of plain or aerated water. Or fish, soup, game, or poultry, mashed
potato, green vegetables, macaroni cheese. Dessert. — Ripe fruit. Beverage. — A glass
of plain or aerated water. The last thing at night. — A glass of milk and soda-water.
Salt is to be carefully avoided.

VL Predigested Foods are indicated in dilatation of the stomach, cancer, and
advanced cases of chronic gastritis. Benger's Liquor Pancreaticus is the usual ferment
employed, because the pancreas contains both a proteolytic and a diastatic ferment.
Taka-diastase is a valuable aid in the digestion of farinaceous foods. The patient
takes it with his food at the commencement of the meal.

1. Peptonised Milk.—rA pint of milk is diluted with a quarter of a pint of water
and heated to a temperature of about 140° F. Two teaspoonfuls of Liq. Pancreaticus,
with 20 grains of sod. bicarb., are mixed with it. The mixture is poured into a covered
jug. and the jug is placed in a warm situation, in order to keep up the heat. At the
end of an hour or an hour and a half the product is raised to the boiling-point. It can
then be used like ordinary milk. Peptonising powders are now to be obtained.

2. Peptonised Beef-Tea. — Half a pound of finely minced lean beef is mixed with a
pint of water and 20 grains of sod. bicarb. This is simmered for an hour. When
it has cooled down to a lukewarm temperature, a tablespoonf ul of the Liq. Pancreaticus
is added. The mixture is then set aside for three hours, and occasionally stirred. At
the end of this time the liquid portions are decanted and boiled for a few seconds.
(3) Other foods can be similarly prepared.

4. Peptonised Nutrient Enemata. — ^The enema may be prepared in the usual way
with a mixture of milk and gruel, or milk, gruel, and beef-tea. A dessertspoonful of
Liq. Pancreaticus is added to it just before administration. Another formula is given
in Formula 74.

Vn. Tapioca 8onp with dream. — Take a pint of white stock and pour into a stew-
pan. When it comes to the boil, stir in gradually 1 ounce of prepared tapioca. Let
it simmer slowly by the side of the fire until the tapioca is quite clear. Put the yolk
of two eggs into a basin, with two tablespoonfuls of cream. Stir with a wooden
spoon, and pour through a strainer into another basin. When the stock is cooled,
add it by degrees to the mixture, stirring well all the while, so that the eggs may not
curdle. Pour it back into the stewpan, and warm before serving. Add pepper and
salt to taste.

VnL Beef-Tea. — Cut up a pound of lean beef into pieces the size of dice ; put it
into a covered jar with 2 pints of cold water and a pinch of salt. Let it warm grad-
ually, and simmer for a couple of hours, care being taken that it does not boil.
^IX. Improved Beef-Tea. — Three-quarters of a pound of steak, scraped or passed
l^rough a mincing machine, and pounded ; f pint of cold water ; one piece of sugar.

304 THE STOMACH [ §§ 218, 212ei

one pinoh of salt, one teaspoonful of tapioca ; simmered in a ** Gourmet Boila ** for
three hours.

X. Artifloial Proteid Foods. — Beef-tea and other meat preparations do not contain
the nutritive constituents of meat, except in small quantities, but contain quantities
of extractives which may derange the digestion and impair the action of kidneys.
Peptonised albuTnin (or peptonised meat) is better, but it is doubtful if the organism
in certain states of prostration can reconstruct peptone into albumin, and the taste
of peptone is very bitter and nasty. The albumoses are intermediate between albumin
and peptone. They are freely soluble, tasteless, and readily absorbed and recon-
structed into albumin, produce no disturbance of the digestive organs, and do not
irritate the kidneys. Somatose is a meat preparation of which the albumin is mainly
converted into albumose, and Stevenson and Luff ^ have drawn attention to its great
value as a nutrient, stimulant, and restorative in debilitated conditions, even when the
presence of albuminuria shows the kidneys are deranged. It is a yellow powder,
freely soluble and tasteless. Plasmon is another artificial proteid food. It is prepared
from milk, and contains casein in a soluble form. It is a nutriment of some value.

XL Milk, Egg, and Brandy. — Scald some new milk, but do not let it boiL Put
it into a jug, and the jug into a dish of boiling water. When the surface looks filmy,
it is sufficiently done, and should be put away in a cool place in the same vessel. When
quite cold, beat up a fresh egg with a fork in a tumbler, with a lump of sugar ; beat
quite to a froth, add a desertepoonful of brandy and fill up the tumbler with scalded
milk.

XII. Chicken Panada. — Take the flesh from the breast of a freshly roasted chicken ;
soak the crumb of a French roll or a few rusks in hot mUk, and put this into a clean
stewpan, with the meat from the chicken reduced to a smooth pulp by chopping it
and pounding it in a mortar ; add a little chicken broth or plain water, and stir the
panada over the fire for a few minutes.

. Xin. Whej. — Into a warm milk put sufficient quantity of rennet to cause curdling,
and strain off the liquid, which is then ready for use.

XIV. White Wine Whej (especially good for infants with summer diarrhoea). —
Half a pint of milk is boiled : as soon as it boils, add 2^ fluid ounces of good sheny ;
allow the mixture to boil for a few minutes, then leave in a cool place in a basin.
When the curd falls to the bottom, carefully pour off the whey, or strain through
mualin. In grave conditions, with vomiting, give a teaspoonful every ten minutes ;
in inflammatory diarrhoea give a tablespoonf ul every hour.

§ 212a. Artificial Feeding of Infants.— General Directions.— Feed the child
regularly ; if necessary, wake it for that purpose. Use a boat-shaped bottle, with a
rubber teat on the end. Feed slowly, holding the bottle on the slope until the milk
in it is finished. Keep the bottle strictly clean by scalding it both before and after
it is used. Mix a fresh portion for every meal. Do not overfeed ; 2 pints of the
mixture in twenty-four hours is enough for a child under six months. No starchy
food should be given to an infant under six months, for the pancreatic secretion is
not established till then. On no account keep a baby at the breast after it is nine
months old — about six months is long enough.

Under One Month. — Feed every two hours from five in the morning to eleven at
night. Start with ^ ounce of milk to i ounce of water, and gradually increase to
1} ounces. Sugar should be added in the proportion of 1 drachm of milk sugar to
4 ounces of the prepared milk. A small teaspoonful of cream may be given with
each feed. When the warm mixture has cooled down, a teaspoonful of lime-water
may be added.

From One to Three Months. — Feed every two and a half hours, with quantities
gradually increasing up to 1} ounces of milk to 2 ounces of water.

From Three to Six Months. — Feed every three hours with 2 ounces of milk to
2 ounces of water, gradually increasing strength to 4 ounces of milk with 3 ounces
of water.

From Six to Nine Months. — Feed with five meals a day. Milk, GJ to 7 ounces,
with water, 2 ounces. With two of the meals add a tablespoonful of some " infant's
food." A little bread and milk, or porridge, or pudding once or twice a day.

1 The Lan eel, September 30, 1889, p. 885.

S 2lia ] ARTIFICIAL fEMDlNG OP INFANfS S06

From Nike to Twelve Months. — ^The bottle may be gradually left off. Morning
and evening, 6 ounces of bread and milk, sweetened. Lunch. — ^Milk and water, bread
and butter. Dinner. — ^Two ounces of farinaceous milk and egg pudding on alternate
days ; a little broth or beef -tea with bread on other days, or meat gravy.

From Twelve to Eiqhtben Months. — Morning and evening, about 6 ounces of
bread and milk, sweetened, and bread and butter. Lunch. — ^Half a pint of milk, bread
and butter. Dinner. — Bread, vegetables, milk pudding, and milk and water. On
alternate days give gravy or broth, with bread-crumb, and milk pudding. Tea. —
Bread and butter, and milk. Half an egg may be given once a day.

From Eiqhtben Months to Two Years. — In addition to the last-named diet,
give minced meat or fish on alternate days, with finely chopped greens and potatoes.
At teatime, cocoa. Mutton and bacon fat, finely chopped, and raw meat juice, are
to be recommended for delicate children.

A useful addition to methods of infant feeding is the use of sodium citrate, 2 grains
to the ounce of milk.^ In this way undiluted milk may be used, so that no cream or
sugar need be added.

^ Dr. Frederick Langmead, Clinical Journal, July 15, 1008.

CHAPTER XI

THE INTESTINAL CANAL

The physiological importance of the intestinal canal is evidenced by the
fact that its length is between 25 and 30 feet, along the whole of which
absorption may take place ; yet the first feature of intestinal disorders
which strikes the student is their inaccessibility to examination. Of late
years grounds have been adduced for believing that bacilli or their toxins
make their way through the mucous membrane of the intestine into the
lymph spaces beneath, and thence into the circulation, particularly when
the mucous membrane is imhealthy, abraded, or ulcerated ; thus intestinal
sepsis constitutes a danger heretofore but little appreciated.^ In the
future, therefore, the bacteriology of the intestinal canal will probably
assume considerable importance, and the examination of the stools will
take its rightful place.

Another striking feature about diseases of the intestines is the dispro-
portionate amount of prostration which accompanies them. For instance,
in a patient who is attacked by a slight but sudden diarrhoea or abdominal
pain, the feeling of exhaustion, which in some cases may amount almost
to collapse, is out of all proportion to the local mischief. This dispro-
portionate degree of prostration or collapse is especially marked in early
life, when " diarrhoea " is, mainly on this account, found to be the principal
cause of death in children imder two years of age. Again, among the acute
specific fevers we find that the most fatal collapse and prostration occur
in those in which the chief lesion is in the intestinal canal — in cholera,
dywntery, and enteric fever. These facts are possibly accounted for by
the circumstance that the chief centre of the sympathetic system (its
" brain," so to speak) is found within the abdominal cavity, in close ana-
tomical relation with the intestines which it supplies with nerves.

PABT A. SYMPTOMATOLOGY,

§ 213. The cardinal symptoms of intestinal disorder are Diarrh(EA,
Constipation, and Abdominal Pain.
Abdominal Pain is frequently present, especially in the more acute

^ Compare §§ 169 and 170, Peritonitis, and Dr. William Hunter, Pernicious Anaemia,
Path. Soc. Trans., 1901-1902, and the Lancet, 1900, voL i.. pp. 221, 296, 371 ; and 1902,
vol. L, p. 1467.

306

§§214,815] SYMPTOMATOLOGY 307

conditions, but by no means always ; and abdominal pain may be due to
so many other diseased conditions within the abdominal cavity that it
has been considered in Chapter IX. (the Abdomen, § 167).

DiARRHOSA is a cardinal symptom of intestinal disorders, and it will be
fully discussed in Part C. of this chapter.

The same remarks apply to Constipation, and in this instance we shall
have to distinguish simple constipation from that important surgical
emergency. Obstruction of the Bowels. This also will be dealt with in
Parte.

The General or Remote symptoms are sometimes, especially in acute
cases, of a very severe character, in view of the profound prostration,
which is associated with some intestinal disorders — to which allusion has
just been made. Pyrexia is not usually a marked feature in intestinal
diseases (see § 165). In the more chronic forms of intestinal disease
emaciation is apt to ensue in course of time. Various nervous derange-
ments of a neurasthenic order are sometimes, as in gastric diseases, asso-
ciated with disorders of the intestinal canal, consequent partly on mal-
assimilation and intestinal toxsBinia, and partly, no doubt, arising in a reflex
manner by intestinal irritation. In rare instances these are of a most
distressing nature, and in one case which I have seen, that of a medical
man, who was unable to obtain relief, they led to suicide. Beflex symp-
toms of a less troublesome order — e.g., vague pains, itching of the nose, or
bad dreams — may be associated with intestinal parasites and some other
intestinal conditions.

PART B. PHYSICAL EXAMINATION.

§ 214. The physical investigation of the intestinal canal can only be
accomplished by two means, the Examination op the Abdomen and the
Investigation of the F^ces.

The Examination of the Abdomen is not always easy, but it should never
be neglected in suspected intestinal disorders. Palpation and percus-
sion will enable us to make out any generalised swelling or localised
tumour. The tenderness which sometimes accompanies intestinal disorders
may also be elicited. Scybala are often present within the colon, and must
not be mistaken for the hard nodules of cancer or other tumour. Their
mobility is a very deceptive feature, and the occasional association of
dianhoea may delude us. Their disappearance after active purgation is
the only certain method of diagnosis. The reader is referred to § 166 for
further details as to examination of the abdomen.

§ 215. An Examination of the Stools is always important, and sometimes
absolutely necessary for the diagnosis of intestinal disorders. A great
deal of information can also be thus obtained with regard to diseases of
the other abdominal viscera. The faeces should be examined first as to
their physical properties — colour, consistence, shape, size, odour, and
reaction; secondly, for undigested food and other substances, such as

308 THE INTESTINAL CANAL [ § 216

mucus, gall-stones, or parasites ; thirdly, for the presence of blood ; and,

fourthly y a microscopic examination is often necessary. It is only rarely

that we can rely implicitly on a patient's statement, even as to the colour

and appearance of the stools ; and, however disagreeable it may be, we

should, when thoroughness is desired, examine the fsBces ourselves. Much

work has been done of recent years on the examination of the fseces —

bacteriological, chemical, and microscopical — by Herter, Schmidt, Stras-

burger, and Cammidge. Early disease of the pancreas and of the intestinal

canal can be detected by the thorough investigations which, however,

can be carried out only in a properly equipped laboratory. For the

technique of these examinations the student should consult the original

writings of the above-named authors.

A small portion of the faeces may be brought in a tin box, but it is preferable to
see them in bulk, the patient having used a night-stool. He should pass water before
going to stool. A large wide-mouthed glass jar, closed at the top by a stopper, is a
very convenient receptacle for their preservation. Nothing should bo added to the
motion until the doctor has examined it. Then carbolic solution (1 in 100) may be
added if wo wish to detect mucus or to preserve the stool.

Physical Properties of the Stools. — 1. The Colour of the faeces is normally
dark brown. The degree of colour of the stools is a fair measure of the
amount of bile which passes into the intestinal canal. When there is
diarrhoea the stools, at first, are dark from excess of bile pigments ; after-
wards they become lighter on account of their dilution by the increased
watery exudation and the presence of imdigested food, (i.) Clay-coloured
stools are found in cases of obstructive jaundice, and pale bulky stools
are also found with defective pancreatic secretion in advanced cases,
(ii.) Streaks qfUood may be present, (iii.) Tarry stools, of a dark or black
colour, are due to the presence of blood which, entering the alimentary
canal high uj) (as in cases of gastric ulcer), has undergone " digestion."
(iv.) Black fceces are seen when the patient is taking iron, bismuth, or
manganese internally, (v.) Colourless ^^ rice-water ^^ or milky stools are
met with in cholera, severe dysentery, or severe entero-colitis, due chiefly
to the presence of serum, (vi.) In infancy the stools are normally of an
orange-yellow colour, but in " dyspeptic " diarrhoea or enteritis they are
generally green,

2. The Consistence of the Stools is normally semi-solid, and the
FORM is that of a rounded cylinder, (i.) When passed in hard, dry,
roundish balls they are known as scybala. These are generally coated with
mucus. Sometimes the irritation they cause sets up a false diarrhcea, and
there are alternating conditions of diarrhoea and constipation, which can
only be cured by a course of aperient medicines, (ii.) In typhoid fever the
stools often present the appearance of j>ea soup. The rice-water diarrhoea
of cholera has just been referred to. (iii.) In cases of stricture of the
rectum — e,g,, from S3rphilis or cancer — the stools are ribbon-like in shape,
and this forms an important diagnostic indication.

3. The Odour of the stools, which is due to skatol, does not give us
much information. There is a characteristic gangrenous odour in severe

I MB] EXAMINATION OF THE STOOLS 309

ulceration — syphilitic, cancerous, or dysenteric. An ammoniacal odour
is never met with in hiunan fscea. If this odour be present it can only
arise from the presence and decomposition of urine.

4. The Reaction of the stools is normally feebly alkaline when first
passed. In pancreatic disease the reaction may be acid. In the course
of a few hours the stools undergo acid fermentation.

Various substances may be found —

1. Undisbsted Particles of Food, if in excess, are indicative of
imperfect digestion (gastric or intestinal), and, unless the food has been
excessive, denote especially intest'nal or pancreatic disease (see also
p. 314), In children this feature usually indicates over-feeding. Small,
hard concretions, consisting of phosphates and other matter, are some-
tiroes found. By noting carefully which articles of diet (proteid, vege-
table, fruit, or carbohydrate) pass for the most part undigested, the physician
learns which the patient should be forbidden to eat.

Fig. ez.— MiososoOMOAL BiAHWinos OF Fscss (»ttar Von J»li»oh).— Normal appMruiiw

2. Miious in the fraces is often overlooked unless specially sought for.
To discover it satisfactorily toaler must be added to the tteces, when any
mucus present will be seen floating about like small pieces of jelly. The
presence of mucus in small amount is of no consequence ; it is usual in
constipation. When in quantity, and intimately mixed tvith the freces, it
indicates catarrh of the smdS, intestine. When in isolated masses it signifies
the presence of catarrh of the large bowel. In membranous, or mucous,
colitis, long cylivderB of mucus are passed, sometimes without much feeces.
These cylinders are generally swarming with B. cdi, which infest the
colon.

3. Blood in the stools may appear either as streaks or in quantity,
when from rectum or large bowel. If it comes from the stomach or small
intestines, it will have undergone partial digestion and give to the stools
a tariy appearance (meleena). In either case it reddens the water in which

810 THE INTESTINAL CANAL [ { 21B

the stool is placed, and gives the cliaTact«ristiG spectrum^ The causes are
dealt with below (g 224).

ng. M.—TsniA SauTTif, HMd X so {al ;
anil proglottldea (b) or wgmaata (•Ughtlr
enlargsd). In the )Ut«r tba utenu bu
esren to ten lateral btmcbei whlth
nmfn. But In T. ICedloonelltta there
ar« twentj' to thirty lateral brancbe*,
' "' ' — 'obranchea

4. Pus always indicates tdceration of the rectum or colon, which may
be of Byphilitic, cancerous, tuberculous, or dysenteric OTigiu (§ 221). Pus

S2161

EXAMINATION OF THE STOOLS

311

is difficult to detect when diarrhoea is present. When in large quantity,
pus indicates an abscess bursting into the bowel, such as a pelvic or ischio-
rectal abscess.

5. Gall-stones may be found by mixing the stools with water, and
passing the mixture through muslin or a fine sieve. Gall-stones sink in
water when recently passed, though they float when dried. They are
very friable, and any suspicious particles should be examined imder the
microscope for cholesterin, see p. 351.

6. Worms, such as tapeworms and threadworms, may be found. It is
of great importance to find the head of the tapeworm. It is about the
size of a pin's head. This may be done by the method just described.

Fig. 68.— Tricooepralxts Dispar (" Whip-
worm ••). — Magnified by 3, and Egg
magnified about 100.

Fig. 69. — AmCTLOSTOMUM DUODBNAIB

(male [smaller] and female). — Worm
and egg x 175. a, natural size.
The lower one is from a micro-
scopic specimen for which the
author is indebted to Dr. W. J.
Tyson, of Folkestone.

Another method is, to mix the faeces with water and let the mixture stand.

As the parasite sinks to the bottom the supernatant fluid should be care*

fully poured off, and more added, the process being repeated until the fluid

becomes colourless. The various worms are given in the Table XVII.

The larv8d of flies are occasionally found.

Microsoopio Ezaminatioxi of the fseces is often necessary, especially to find the ova
of parasites. Plaoe a small portion of the stool upon a slide, and it not sufficiently
fluid, dilute with a quantity of normal saline solution ; cover and examine. If dysen-
tery is suspected, the stool must be examined whilst still warm. Nobbially, under
the miorosoope (Fig. 62), the stool shows undigested particles of food, especially

by the spectroscope. It appears that in certain as yet unknown conditions some
pigment isprofleQt in the fsMe8»[wbich on exposure to the air becomes red like blood. —
Carter and McMann, the Lancet, November 25, 1899, p. 1432.

812

THE INTESTINAL CANAL

[{215

;-g >»'d

- « o >» »

3 JS •

>» • S

o a>

" s

•«'

»o

pig

SXAUINATIOH OF TBS STOOLS

i ii ill I
III, 1 1 ill

ifljiii

Hi I (TV

314 THE INTESTINAL CANAL [ {§ 815a, 816

Btaroh granules, muscle fibres, connective tissue, and fat cells ; crystals of fatty acids,
oxalate of lime, and other calcium salts. Hsematoidin, phosphates, cholesterin, and
Charcot-Leyden crystals are rare. Among the bacteria the Bacillus coli communis,
various unnamed bacilli, cocci, and yeast are found. Blood corpuscles and intestinal
epithelial cells may occur in small amount.

Among the abnormal constituents which should bo looked for are, first and chiefly,
the presence of the ova or segments of the different entozoa (see below, { 215a).

2. Among the undigested food products an excess of undigested starch or of muscle
fibre indicates disease of the small intestine or pancreas. An excess of fat in the
faaoes indicates (i.) deficient bile secretion, (ii.) disease of the pancrecks. or (iii.) intestinal
disease interfering with fat absorption. The relation of unsaponified to saponified
fat is normally about 10 to 15 per cent. In pancreatic disease the unsaponified fat
is in excess. In biliary obstruction the saponified fat is in excess. In cancer of the
pancreas, with jaundice, the relations are about equal.

3. The Charcot-Leyden crystals are the only abnormal crystals of any importance.
They are very rare, and are found chiefly in association with worms, especially anky-
lostomum. Their presence is a useful indication that the parasite is still alive in the
intestinal canal. Excess of fatty acid crystals is found with pancreatic disease.

4. Various hacUli, such as those of typhoid and cholera, are present in the feces
in disease, but on account of the many extraneous microbes it is almost impossible
to obtain specific cultures from the stools. The b. cdi has its normal habitat in the
colon. Abrupt alterations in diet are followed by rapid alterations in the prevailing
types of bacteria, and this is true also after the administration of lactic acid bacilli
in certain putrefactive conditions.

5. The amcsba of amoBbio dysentery is characteristic. It was first found in the
stools, and described by Losch in 1875, and termed by him the amoeba colL They
are generally found in a drop of freshly voided mucus in fair abundance as roundish
cell-like bodies of irregular oval form, which continually undei^go amoeboid movements
on a warm slide. Their size varies from 10 to 20 fi.

S 815a. yarioQi Inleitinal and Other Parasilei, or segments of them, or their ova,
may be found in the faeces. Those are described in Table XVII., and the accompany-
ing illustrations. Seven of these infest the alimentary canal of man : The two common
tapeworms (T. Solium and T. Mediocanellata), recognised by their segments in the
faeces, naked eye ; the tapeworm of central Europe (Bothriocephalus Latus), recognised
by its segments, naked eye ; the extremely common threadworm (Oxyuris Vermicu-
laris) ; and the common round worm (Ascaris Lumbriooides), both of which may be
seen by the naked eye, the former like small pieces of cotton, the latter as large as a
garden worm ; and two worms which are chiefly found abroad, the Ankylostomum
and the Tricocephalus, both of which, with their ova, need magnification for discovery.
The ova of various forms of Bistoma may also be found in the faeces (§411). The
symptoms and treatment of the common worms are given in | 226. The eggs of the
Bilharzia are sometimes found in the faeces, enclosed in small fleshy masses, but they
are chiefly found in the urine, associated with hcsmaturia (§ 300). The ova are quite
peculiar in having a spine-like projection at one end or at the side (Fig. 89).

PART C. DISEASES OF THE INTESTINAL CANAL, THEIR DIAGNOSIS,

PROGNOSIS, AND TREATMENT.

§ 216. Bontine Procedure, and Classificaiioii.— Having first ascertained
that the patient's Leading Symptom is referable to the intestinal canal ;
and secondly, by inquiries into the History of the illness, whether it
came on acutely and suddenly or gradually in a chronic manner ; we proceed,
in the third place, to the Physical Examination of the abdomen after
the manner set forth in Chapter IX. (§ 166). If, in the course of these
inquiries, definite disease is suspected in any particular organ, reference
hould afterwards be made to the appropriate chapter.

HB17,218]

DIARRHCEA

S15

A. If Diarrhoea is the leading sTmptom :

If acute, or attended by choleraic or dysenteric

sjnnptomf
If chronic . • . . . . . . . .

torn to H 218-220
§ 221

§ 223

„ §§ 224-226
§ 227
§ 228

B. If there is Tenesmus without diarrhoea

C. If Blood or some other alteraiioii in the stools is

the leading feature

D. If Constipation is the leading symptom

E. If the Stoppage in the Bowels is complete . .

§ 217. Diarrhoea is the frequent occurrence of loose or liquid motions ;
it is the watery consistence of the stools which is the chief characteristic
in diarrhoea. A frequent call to stool may arise from some local irritation
(see Tenesmus), without any alteration in the consistence or form of the
stool. This source of fallacy should be carefully guarded against. Many
women speak of the tenesmus which sometimes accompanies the menses as
" diarrhoea."

Causes of Diarrh(ea.

Acate.

Chronic.

I. Irritating food.
II. Watsr.

III. Intestinal parasites.
IV. Infantile diarrhoda.
V. Toxic blood conditions.
VI. Acute enteritis or " chUl."
VII. Acute ulcerative colitis.
VIII. Some causes of chronic
diarrhoea.
IX. Dysentery.
X. Cholera.

I. Acute causes becoming chronic.
II. Local conditions about anus.

III. Ulceration (colitis, tuberculosis,

cancer and B3rphili8 of the
bowel).

IV. Chronic colitis or mucous colitis.
V. Portal obstruction or congestion.

VI. Dysenteric diarriiosa.
VII. Nervous diarriiosa.
VII I. Amyloid disease.
IX. Senile diarrhoea.
X. Mineral poisons {e.g., arsenic).
XI. Pancreatic disease.
XII. Psilosis.

The fsBces should always be examined where it is possible (§ 215).
Sometimes the situation of the disease may thus be discovered ; for instance,
when the stools are coloured with bile, and contain undigested food, and
small jneces of mucus intimately mixed with the faeces, catarrh of the small
intestine may be suspected. When mucus or " slime " occurs in larger
masseSy in " strings " or " casts," there is probably disease of the large
intestine.

§ 218. In Acute Diarrhoea there is usually a good deal of pain and
tenesmus (straining at stool) ; the tongue is usually furred, there is thirst,
and may be vomiting. If there be much vomiting and prostration, the
diarrhoea is probably due either to the presence of some violent irritant, or
to some serious organic lesion, such as injury to the bowel or peritoneum.
In profuse diarrhoea the temperature is usually subnormal, and the urine
diminished. It should be borne in mind that scybala retained in the
intestines may give rise to attacks of diarrhoea alternating with con-
stipation.

316 THE INTESTINAL CANAL [ % 218

Causes. — ^I. The food taken, and the vessels in which it has been con*
tained and cooked, should be the first questions in all cases of acute
diarrhoea coming on suddenly in a healthy person. Collapse and many
of the symptoms of cholera can be produced by food cooked in a new
copper vessel. One of the irritant poisons may have been introduced into
the food accidentally or designedly. This should be borne in mind ;
and in cases of sudden and unexplained diarrhoea the physician should
patiently consider every article taken at every meal during the preceding
twenty-four hours. Over-ripe or decomposing fruit, too much raw
vegetable food, tinned meat— especially that which has been long in store
and has imdergone a change resulting in the formation of ptomaines (see
footnote, p. 194) — shellfish and bad cheese are also possible causes. In
this variety of acute diarrhoea there may be a considerable degree of
intestinal colic (§ 172). The first or diarrhoeal stage of i^ichinosis comes
under this heading, and should be considered in pork-eating coimtries.
In cases of acute diarrhoea in which trichinosis is suspected the worm
should be sought in the feeces, for in the earlier stages of this disease treat-
ment is so much more efficacious. The diarrhoea which precedes the in-
testinal obstruction caused by intussusception in children frequently
follows a heavy meal of indigestible articles ; and diarrhoea is itself a cause
of intussusception.

II. The quality of the water is often responsible for diarrhoea, acute
or chronic. This is frequently the case in malarial districts in the summer
and autumn, especially when the temperature is high. Water containing
much peat from the moimtains may also cause diarrhoea ; and thus the
water supply of the town of Montreal frequently occasions diarrhoea in
new-comers.

III. Worms may give rise to diarrhoea in children. They may be
attended by uneasy abdominal sensations, night terrors, picking of the
nose, itching of the anus, but sometimes the worms are discovered
in the stools when there have been no symptoms pointing to their
existence (§ 226).

IV. Infantile Diarrhoea occurs in at least three well-recognised clinical
forms : (i.) Acute Dyspeptic Diarrhoea ; (ii.) Inflammatory Diarrhoea or
Entero-colitis ; and (iii.) Epidemic Diarrhoea or " simmier diarrhoea "
(including Infantile Cholera) — mentioned in progressive order of severity.

(i.) In Acute Dyspeptic Diarrhcea the stools are offensive, frothy,
of a greenish colour, and mixed with curds of imdigested food. Vomiting
may or may not be present. It is usually a transient condition if ade-
quately treated.

(ii.) In Infantile Inflammatobt Diarrhcea (Entero-colitis) the stools
are green, slimy and often contain blood ; there is some fever at the
beginning, and abdominal distension. The inflammation attacks chiefly
the colon, consequently there is tenderness on pressure over the region
of the colon, and mucus in the stools. Adults also are sometimes affected.
It lasts only one to three weeks if treated as described below.

i 218 ] ACUTE DIARRH(EA 317

(iii.) Epidemio Diarrh(ea (" summer " or " autumnal " diarrhoea o£
children) is met with chiefly in childhood and infancy in the autumn
months of the year, and is attended by catarrh of the mucous membrane
of the bowel. The symptoms of a severe attack are : Watery stools, foul-
smelling, of altered colour, containing lumps of mucus ; vomiting ; acute
abdominal pain and tenesmus ; prostration, collapse, subnormal tempera-
ture, with pinched aspect, rapid wasting, and often (after a course of a
week or so) death from exhaustion. Infantilb Cholera forms about
2 per cent, of '* summer diarrhoea " cases. The stools are serous, persistent
vomiting is a marked feature ; great collapse rapidly supervenes, the tem-
perature in the rectum is raised as in adult cholera, and death soon
follows. Some describe it as a separate affection, but it is probably a
severe form of Epidemic Diarrhoea.

Etiology of Infantile DiarrhcBa. — Any of the previously mentioned causes
(I. to III.) are contributory, and very often exciting, causes in all forms
of infantile diarrhoea; and especially dietetic errors. This latter is the
sole cause in variety i., and probably in variety ii. These diseases affect
chiefly hand-fed children, in warm weather, being probably in part due
to dirty feeding-bottles, teats, sour milk, etc. Most of the cases occur
in children imder six months old. The causes of Epidemic DiarrhoM are
far more obscure, (i.) Seasonal, epidemic, and microbic causes^ have
long been suspected on account of its prevalence during the summer and
autumn months. It occurs chiefly after hot, dry summers, and the
researches of Ballard seem to point to its being dependent upon some
telluric condition, (ii.) It occurs chiefly in towns, and certain localities
— e.g., Leicester — are notorious for a lethal epidemic each summer and
autumn. Ballard found that the severity of the annual outbreak seemed
to vary with the subsoil temperature ; it started when the 4 feet earth
thermometer read 56° F. Adults do not altogether escape the influence
of these causes, and diarrhoea is widely prevalent in the hot, dry siunmer
months in some years; but in children the death-rate is sometimes
appalling)

In the Treatment of Infantile Diarrhoea astringents are not only useless,
but harmful. Equal parts of lime-water and castor oil (F. 64), every two
or three hours, imtil the stools become healthy is a most valuable pre-
scription. This must be combined with appropriate diet. The milk must
be sterilised and diluted with lime-water. Where cows' milk cannot be
retained, condensed milk, whey, or raw meat juice may be tried. The
vomiting may be checked by giving only barley-water with white wine
whey (§ 212) for a time, and the usual stomach sedatives. In mild cases
castor oil, followed by bismuth, rhubarb, soda, and cinnamon, or small
doses of grey powder or thymol will effect a cure. In epidemic diarrhoea
milk must immediately be stopped, and only whey, or albumen water
(white of one egg to half a pint of water), or plain boiled water administered

^ Waldo considers epidemio diarrhoea to be due to local rather than to climatic
conditions. — ^Milroj Lectures, the Lancet, Biaj, 1900.

318 THE INTESTINAL CANAL [ § 218

temporarily. With cessation of the diarrhoea, the return to milk should
be gradual. In cases with collapse, brandy is to be given, and the child
should be put into a warm mustard bath or hot pack until the skin, which
is harsh and dry, becomes soft and elastic. The subcutaneous injection
of from 5 to 10 ounces of sterile saline at a temperature of 100° F. ia the
most efficacious remedy, and hypertonic saline and sea- water injections are
now on trial. Calcium chloride is useful to check the serous exudation.
If vomiting persists, it may often be checked or diminished by washing out
the stomach. This is easily done by using a soft rubber tube with a large
eye, and a funnel. For persistent offensive motions rectal irrigation
with saline is useful.

V. Toxic Blood States. — Enteric fever is nearly always attended by
diarrhoea ; it sometimes complicates measles, and the other eruptive fevers
(especially at their advent). Graves' disease, chronic renal disease, ureemia,
and pyaemia ; and sometimes it appears at the termination of acute condi-
tions, as in pneumonia. It may also be one of the effects of dissecting-
room poisoning. Grouty people are often subject to attacks of diarrhoea,
which are of a conservative nature.

VI. A chill to the surface in some individuals will determine an attack
of acute diarrhoea.

YII. Acute Ulcerative Colitis is usually of sudden onset, with diarrhoea,
and abdominal pain occurring in paroxysms. The motions are dark,
offensive, and contain mucus and blood. There is tenderness over the
colon, especially over its ascending portion, which is usually distended.
The tongue is furred at first, and the breath very offensive. Pyrexia
may be present, about 101° to 102°. The commonest complications are
perforation, peritonitis, profuse haemorrhage, and anaemia. Death may
occur from exhaustion in one or two months. The ulcerative colitis of
asylums is usually more severe, with vomiting and rigor, and may terminate
fatally in a few weeks. Both diseases affect chiefly females about middle
life. It may in some cases be difficult at first to diagnose from Enteric
fever.

VIII. In cases of acute diarrhoea in which the cause is obscure, reference
should be made to the other Causes of Chronic Diarrhoea, any of which
may from time to time give rise to an acute attack. Dysentery (§ 219) and
Cholera (§ 220) are the commonest causes of diarrhoea in tropical climates,
and are occasionally met with in this country.

Prognosis of Acute Diarrhoea, — The causes of acute diarrhoea are for the
most part removable ; and though weakened by the attack, the patient
generally makes a good recovery. Acute Epidemic Diarrhoea in children,
however, is a most fatal affection, and it leads to a higher death-rate in
infancy, in Great Britain, than any other disease, accounting for nearly
3,000 deaths annually in London alone. Briefly, the prognosis in any given
case depends upon (i.) the cause ; (ii.) the severity of the symptoms and
the evidences of weakness ; (iii.) the state of the patient's hygienic sur-
roundings ; and (iv.) the effects of treatment. Infantile cholera is rarely

§ 219 ] ACUT£! DIABBHCBA^DYSSNTER Y 319

lecovered from. Dyspeptic diarrhcBa may be ouied in a few weeks, but if
untieated, is apt to go on to subacute enteritis. Without treatment all
forms of epidemic diarrhoea, even in adults, are serious. Should sjrmptoms
of prostration or collapse ensue, the outlook is bad ; but it is only at the
two extremes of life that this disease is so grave. Ulcerative colitis is very
serious ; if death does not occur from complications, it usually occurs from
the exhaustion, ansemia, or relapses.

Treatment of Acute DiarrhcBa, — The indications are (a) to remove any
irritating matters present in the intestinal canal ; (6) to ensure rest to the
irritated parts ; and (c) to check excessive exudation, (a) Thus, a simple
acute diarrhoea in an adult following the ingestion of bad food is cured
readily by a dose of castor oil (J oz.) with tr. opii (l\x.) ; or calomel.
(b) Milk and bland food only can be taken ; soups and beef -tea are not
advisable. In severe cases withstanding treatment, the diet may be
restricted to raw meat juice. Simple cases of dyspeptic diarrhoea in chil-
dren are readily cured by grey powder every night, and alkaline carbonates
during the day. If the stools are slimy, bismuth is needed, (c) After
the expulsion of all irritant matters, a mild astringent, such as chalk or
Dover's powder, is beneficial, and bismuth to soothe the congested mucous
membrane. Astringents are contra-indicated in the early stages of diarrhoea,
especially when due to (i.) irritants; (ii.) inflammation; or (iii.) portal
obstruction. Only when the diarrhoea threatens to become chronic do we
require to use astringents, such as catechu, kino, pulv. cretae aromaticus,
mineral acids, hsematoxyliu, and tannin. Opium allays irritation and
checks peristabis ; it may be given as tr. opii or tr. chloroformi et mor-
phiniB. Goto is a useful drug ; it acts by diminishing the intestinal secre-
tion. If the stools are very ofEensive, calomel, charcoal, carbolic acid,
and creosote are useful ; and a course of intestinal antiseptics may be
given — salol (gr. x.), j8-naphthol (gr. v.), thymol, etc. Lastly, when other
means fail, rectal injections must be resorted to — opium with starch, or
silver nitrate ; but these are useful chiefly when the disease is in the larger
bowel. In all severe cases, absolute rest must be insisted upon, with
warmth to the abdomen;

The patient, who is or has been living abroad, complains of severe diabbh(Ea» with
BLOOD, MXTCTJS, and perhaps pus in the stools. The disease is probably Dysenteby.

§ 219. VllL Dyientery is a form of diarrhoea which occurs in marshy and malarial
districtB, attended by severe tenesmus and frequent stools, and generally with pyrexia,
due to ulceration of the large bowd, and depends on the presence of one or more
specific organisms. It is met with clinically in two forms — (a) acute and (6) chronic
Both are characterised by (i.) diarrhoea, (ii.) the passage of blood, and (ill.) of mucus,
from the bowel.

(a) AouTX Dysbnteby may be of sudden onset. The patient wakens in the early
morning with a griping pain, and tenesmus, and during the day there may be from
ten to sixty scanty discharges from the bowel, containing blood, mucus, epithelial
cells, and later on they acquire the appearance known as the '* toad-spawn '* discharge.
In other cases there is abdominal pain and malaise for a few days before the onset of
the diarrhosa. A moderate degree of fever may be present ; if at all high, suspect the
complication of malaria and liver abscess. In a favourable case the discharge ceases
after a week or ten days.

320 THE INTESTINAL CANAL [ § 219

(6) Chronic Dysentery may result from an acute attack, or it may be chronic
from the onset. In the latter form the patient has a gradually increasing diarrhcda,
the stools becoming frequent and scanty, with some tenesmus, and the passage of a
little blood or flakes of mucus, the symptoms gradually becoming worse. Dysentery
affectfl the rectum, sigmoid flexure, and descending colon. Sometimes the disease
extends as far up as the caecum, and may consist merely of a catarrhal state of the
mucous membrane. Severer cases lead to vlcerative cditia, when shreds of
mucous membrane may be passed, and this may result in thickening and cicatricial
tissue, and stricture. The most severe variety, however, is the sloughing or
gangrenous form, when large sloughs come away with an offensive odour, and are
liable to set up septicsemia, or to cause perforation of the bowel, or even a fatal
hsemorrhage.

Etidogy. — Dysenteiy most often affects men, especially if intemperate. True or
Amoebic Dysentery occurs in the tropics, where it is epidemic and endemic, and is
due to the presence of the amoeba coli (see § 215). It is supposed that it enters the ali-
mentaiy canal by the drinking water. It is more apt to affect unhealthy persons,
and is predisposed to by any disease or abrasion of the alimentaiy canal, such as
occurs after eating unripe fruit, a chill, the abuse of purgatives, and especially con-
stipation. In heart and kidney disease, secondary diphtheritic enteritis may occur,
which is known as dysenteiy, but the description above refers mainly to true dysentery.
Shiga's bacillus is frequently found in epidemic and sporadic cases of dysenteiy, and
is the cause of such cases as are not due to the amoeba.

Diagnosis. — ^The only pathognomonic features are the presence of the amoeba coli, or
the agglutinative reaction to Shiga's bacillus. In the amoebic form of dysenteiy there
is usually a histoiy of an insidious beginning, and there is a greater tendency to the
formation of liver and other abscesses than in the bacillaiy form. Acute dysenteiy
may be mistaken for acute diarrhoM, from which it is differentiated by examination
of the stools. Acute enteritis due to malaria may be regarded as dysentery, and unless
the case be treated with quinine the patient will die; the blood in such cases should
be examined for malaria parasites. A diagnosis of chronic dysentery should never be
made before local examination has excluded rectal cancer, polypus, piles, bilharzia,
and, indeed, any of the other causes of diarrhoea (p. 316). Dianlioea due to ulceratum,
occurring in a tropical climate, may be mistaken for chronic dysenteiy. The ova of
bUharzia hcsmatohia may be foimd in small masses resembling polypi which, on being
broken up and examined by the microscope, show the ova (§ 300). The patient will
also have a histoiy of hsematuria.

Prognosis. — An attack of acute dysenteiy in a healthy person may pass off in a
week or so ; but it requires care in a tropical country to prevent it passing on to chronic
dysenteiy. a condition which is veiy difficult, often impossible, to cure. The sloughing
form is extremely dangerous, being so often complicated by grave conditions, such as
local abscesses. With chronic dysenteiy acute exacerbations frequently occur, and
the patient becomes anemic and greatly debilitated by the constant loss of blood.
Complications arising in the course of chronic dysentery are ulcers, with consequent
periproctitis, abscesses of the liver, cicatrisation with rectal stricture, peritonitis,
multiple pyemic abscesses, and pneumonia.

Treatment. — The main indication in both acute and chronic dysenteiy is to give
rest to the inflamed part. This in the acute form is accomplished by keeping the
patient absolutely at rest in bed, with no food except white of egg, barley water, chicken
broth, etc., for a day or two. Ipecacuanha is the best remedy for amoebic dysentery.
A small dose of castor oil and laudanum may be given at the outset, and if this does
not cut short the disease, ipecacuanha must be administered in doses of 25 to 30 grains
at a time. The patient is so apt to vomit the remedy that special precautions must be
taken in its administration. A dose of opium is administered, and the ipecacuanha
given when drowsiness begins ; and no food should be taken for three hours before and
after the drug is given. The patient must be kept lying down, the head low, and no
movement permitted. For the bacillaiy form, magnesium sulphate (1 drachm every
hour) is given until there is no more blood and mucus and no temperature. It rarely
requires to be given longer than three days. Hot fomentations are used for the
abdominal pain. Opium in staroh enemata relieves the tenesmus ; or the bowel may

$ 880 OBOLSBA 321

be washed out with boraoic solution. For the baoillary form of dysentery serum
treatment, 20 c.c. twioe daily, should be given early.

In ohronio dysenteiy the diet must be non-irritating, but it is not good to keep
the patient too long on mUk food. Sometimes the patient may recover rapidly on
being sent a sea voyage. Constipation must be avoided. Astringents must very
rarely be employed, though Bael fruit is advocated by some. Enemata are the most
useful form of local treatment. Inject slowly 1 to 2 pints of a solution of quinine
sulphate (1 in 5,000, increased to 1 in 1,000), or of aoetozone (1 in 2,000). They
should be administered warm (see also § 221, IV.). Castellani has a vaccine useful
as a prophylactic.

The patient complains of aoutb diabbh<ea coming on very suddenly, and attended
with severe oollafsb, abdominal cramps, and " rice-tDoter " stools. The disease if
probably Choleba.

S 220, IX. CQidlera (synonym: Asiatic Cholera) is a disease, due to the comma
bacillus of Koch, which commences with urgent vomiting, purging, and colourless
evacuation, cramps and a tendency to collapse, and which, if not fatal in the first
stage, is attended by secondary fever. The period of incubation is usually three to
six days, but it may vary between one and ten.

There are three well-marked stages :

(a) Stage of evacuation, which lasts from two to twelve hours, or longer. The
patient is suddenly seized with violent vomiting, severe cramp, and profuse diarrhcsa.
The stools, after the first few, are colourless and opaque, resembling rice-water, and
containing flakes of columnar epithelium and oasts of villi ; and the commO'Shaped
bacillus (§ 627). There is severe cramp in the fingers, toes and abdominal muscles,
great exhaustion, small and weak pulse, and coldness of the body, {b) The algide
stage, cold stage, or stage of collapse, lasts a few hours to a few days according to the
severity of the case. The patient becomes like a corpse ; the surface temperature
goes down, and the skin becomes a deadly livid hue ; the pulse cannot be felt at the
wrist. The temperature is most remarkable, for in the rectum it may be as high as
105** F., while in the axilla it is only 90° F. During this stage the purging ceases, but
the vomiting and cramps persist. The mind remains clear. There is suppression of
urine and bile, (c) SUnge of reaction, — ^The pulse returns, the temperature rises, the
bile reappears, the urine is scanty and deficient in urea. The temperature goes up,
and may be attended by typhoid symptoms. The boweb are confined. There may
be erythematous, urticarial, and other eruptions upon the skin. This stage is followed
by great weakness.

The Diagnosis is easy in severe cases on account of its extreme suddenness and
the severity of the symptoms. The copious colourless evacuations are charaoteristiu
of cholera. The only condition which resembles it is acute poisoning by arsenic,
croton oil, and other irritants. The identification of the bacillus renders the diagnosis
certain.

Etiology. — ^The disease occurs in great epidemics, but it fortunately has not visited
this country, except sporadically, since 1865-6-7. Prior to that date there were
epidemics in 1854, 1848, and 1832. In India it is endemic, just as typhoid fever is
endemic in London. As regards age, none are exempt. The season of the year in
which all epidemics in this countiy have occurred has been the autumn and the end
of the summer. A hot, dry summer predisposes, but the disease is seen in Russia
during the winter. The exciting cause is a specific organism, which must be introduced
into the alimentary canal. As in enteric, the disease is commimicated by the evacua«
tions from the bowe]s and stomach, and requires the same preventive measures
(§ 390 et seq.). Fresh evacuations will not produce the disease, but only when they are
slightly decomposed, for they take three, four, or five days to become infectious. The
disease is usually communicated by drinking water which has become contaminated.
But it may be conveyed in other ways, as by flies, through VKtnt of cleanliness. One
attack does not give immunity from a second.

Prognosis. — It is a very serious disorder, and nearly all earlier cases of an epidemic
are fatal. The average mortality was 60 per cent. Patients died in the algide stage,
but the newer methods of treatment have reduced the mortality by half. In the

S22 THE INTESTINAL OANAL [ S 821

reaotion stage ursemic ooma, hyperpyrexia, or the typhoid state may cause death.
Untoward Symptoms are blood in the evacuations, long stage of collapse, restlessness,
extreme cyanosis, and absence of the pulse at wrist. Favourable signs are a perceptible
pulse in the algide stage, the early occurrence of reaction, cessation of cramp, secretion
of urine, and the occurrence of sleep. The commonest Complications are pneumonia,
occurring in the rei^ition stage, bronchitis, pleurisy, parotitis, bed-sores, inanimation
of the phaiynx, genitals, or bladder, and corneal ulcers.

There are two stibvarieiies : (1) Choleraic diarrhcea, or " cholerine " — that is, cases
like autumnal diarrhoda occurring during an epidemic of cholera. (2) Dry cholera,
that is, where there has been no vomiting ot diarrhoea, but all the other symptoms
These cases are rare.

The treatment of cholera has been more hopeful since the introduction of Major
Leonard Rogers* methods. Opium (nixx.) may be given at the onset of the pre-
liminary diarrhoea, but never after the characteristic colourless evacuations have set
in. Rest in bed, warmth, and fluid farinaceous diet are essential ; animal albumens
in soups and jellies are harmful. Observation of the specific gravity of the blood
in the collapse of cholera, and of the failure of normal saline injections, led Major
Rogers to employ the hypertonic injections which have been so successful in the
treatment of this dreaded disease. When collapse appears, saline injections by
rectum are useful so long as the blood-pressure is above 70 millimetres ; below that point
they are not absorbed, and an intravenous injection should be administered of sufficient
amount (3 to 4 pints) to raise the blood-pressure to normal, and ensure excretion by
the kidneys. The solution advocated contains sod. chlor. gr. 120, oalc. chlor. gr. 4,
postass. chlor. gr. 6 to a pint of sterile water. Potassium permanganate gr. 2 is given
by the mouth every half-hour as an oxidising agent, which destroys the toxins of the
cholera bacillus. For details Major Rogers* book^ must be consulted.

§ 221. Chronic Diairhoda. — The term chronic diarrhoea signifies the
occurrence of frequent loose evacuations, say three or more in the
twenty-four hours, extending over a period of weeks, months, or even
years (as in Sprue). It is usually, though not necessarily, attended by
tenesmus. The stools should be examined (§ 215) whenever the cause is
doubtful. In all intractable cases the anus should be carefully inspected.
Tenesmus points to the presence of disease of the rectum.

L Chronic Diarrhoea may be due to some of the same causes as Acute
Diarrhoea (q*v.). In children tuberculous ulceration of the intestine, in-
tussusception, worms, or bad feeding ; and in adults, errors in diet, ulcera-
tion, and chronic irritant poisoning, should be remembered.

II. Fissure of the Anns, slight ulcers or abrasions, or even an inflamed
pile, may cause a chronic diarrhoea, which baffles investigation for a long
timei

III. Ulceration of some part of the Intestinal Canal is perhaps the com-
monest cause of chronic diarrhoea in England, and it will be well to mention
here all the ulcerating lesions which may affect the intestine, in order
from above downwards. (1) Simple ulcer of the duodenum is a rare
condition which may arise from bums, or from the same causes as simple
ulcer of the stomach (§ 207). There may be few or no symptoms till
sudden peritonitis or copious heemorrhage and melsena occur. (2) Ulcer
of the lower part of the ileum may be due to tuberculosis or typhoid fever.
(3) Ulcer of the caecum may arise from the pressure of inspissated faeces
or some foreign body — e,g., the bristle of a tooth-brush — which has been

({

Cholera and its Treatment," Oxford University Press, 1911.

§ 881 ] CHROMIC DIARRH(EA-^0LITI8 323

swallowed. (4) Ulcer of the vermiform appendix may similarly arise
from foreign bodies or as part of appendicitis (q.v,), (5) Ulcer of the
rectum is generally of malignant or syphilitic origin ; it is attended by the
passage of blood and pus, and stricture may result. (6) Ulcers of the large
intestine and rectum occur in the later stages of dysentery. These may
contract on healing and produce stricture. (7) Cancer of the bowel may
produce ulcer in any part of the bowel, but the most frequent situation is
the sigmoid flexure. (8) Bright's disease, severe anaemia, and other
wasting diseases. (9) To these some add catarrhal ulceration (§ 218, VII.).
(10) Ulceration may follow prolonged constipation with atony of the
colon.

The commonest causes of ulceration in this country are Colitis, Tuber-
cle, Syphilis, Cancer, and in tropical climates Dysentery (§ 219).

1. Colitis, inflammation of the colon, occurs in two forms, ulcerative
(§ 218, VII.) and mucous (see IV. below) ; and is one of the most intractable
forms of chronic diarrhoea.

2. Tuberculosis of the lungs may be attended by diarrhoea, even
without ulceration of the bowel, and in such cases the diarrhoea is con-
sidered to be one of the symptoms of the hectic fever in pulmonary tuber-
culosis, or due to swallowing of the infected sputum. Tuberculous ulcera-
tion is recognised by (i.) evidences of tuberculosis in the lungs or other
part of the body; (ii.) the presence of night sweats « and intermittent
pyrexia ; (iii.) the stools are watery and bilious, and there is rarely any
pain. Relief is generally efEected by quinine and opium internally, com-
bined with appropriate dietary ; if these fail, recourse may be had to per-
nitrate of iron, opium, and lead.

3. Intestinal Cancer presents the following features : (i.) The patient
is usually over forty-five or fifty, and there may be a family history of
cancer ; (ii.) there may be cancer in the glands or other parts of the body,
and there is almost always a history of emaciation f receding the diarrhcsa ;
(iii.) paroxysmal abdominal pains are frequent, and if the disease is in the
rectum there is great pain and tenesmus on passing a motion ; if it be not
in the rectum, a tumour can generally be made out through the abdominal
wall ; (iv.) the stools vary, but very often contain blood in considerable
quantity.

4. In Syphilitic Ulceration of the bowel (i.) the motions often consist lai^eiy
of pus and blood ; (ii.) great pain and tenesmus are usual, combined with (iii.) other
evidences and a history of syphilis, (iv.) Opium and antisyphilitic treatment are here
of great value to cheek the diarrhoea.

IV. Chronic Colitis or Mucous Colitis is in its early stages frequently
overlooked, when the patients complain perhaps only of " nerves." The
symptoms are (i.) attacks of diarrhoja alternating with constipation.
During the attacks (ii.) mucus is found in the stools. The mucus may
be passed in masses, shreds, or casts several inches long. Occasionally
blood is also passed, indicating ulceration. The f89ces contain intestinal
sand in one-tenth of the cases, (iii.) The general health is lowered, asso

324 THE INTESTINAL CANAL [ § 221

ciated with despondency and other symptoms of nervous prostration,
together with (iv.) abdominal discomfort and sometimes paroxysms of pain,
(v.) Examination may reveal a distended and tender colon, particularly
over the sigmoid ; or spasmodic contraction of the descending colon may
be felt. The sigmoidoscope is used as an aid to diagnosis in obscure cases.

Course. — The attacks last at first a few days only, then for weeks or
months ; the patient may at times pass nothing but mucus by the bowel.
The disease is not of itself fatal, but is often very intractable to treatment.
It leads to neurasthenia, emaciation, and, in the more serious cases, death
from asthenia or complications. Relapses may continue for ten years or
longer.

Treatment, — ^During the attacks rest, warmth, bismuth, and milk diet
is essential. Between the attacks treatment is directed to prevent irrita-
tion of the mucous membrane by correct diet and prevention of accumula-
tion of faeces in the colon. All seeds, skins, and stringy foods must be
forbidden ; examination of the faeces reveals that at some stages all fruits
and vegetables are imdigested, and should therefore be avoided. Combe,
of Lausanne, has foimd that nitrogenous foods favour putrefaction, and he
obtains successful results on a diet which is largely carbohydrate. The
colon must be kept empty ; this may be effected by ^ to 1 oimce doses of
castor oil daily, or other measures described under Constipation in § 227.
Lavage of the col6n daily, or twice weekly, with plain or medicated water,
is now practised at Plombieres, Harrogate, and other spas, and may be
carried out at home imder careful medical supervision. Vaccines have
assisted some cases. If the disease resist medical treatment, caecostomy
or appendicostomy may be performed, through which the colon b flushed
out daily.

V. Obitmotion in the Portal Oiroulation produces diarrhoea, due to the congestion
of the intestinal wail. It is recognised by : (i.) A previous history of heart disease,
or of intemperance and alcoholic dyspepsia ; (ii.) other signs of liver or cardiac disease ;
(i.i.) other evidences of portal obstruction, such as ascites, piles, and a large spleen
(§ 233) ; (iv.) there is little or no pain, and the stools are liquid and dark, occasionally
bloody. The Treatment requires caution, because the diarrhosa and haemorrhage of
themselves relieve the condition by diminishing the venous engorgement, (i.) li the
diarrhoea has not lasted long, a large dose of calomel will relieve the portal congestion,
and so cure the diarrhoea, (ii.) Magnesium sijJphate (20 grains), with alum and dilute
sulphuric acid, are recommended ; bismuth and opium, with caution, are the most
useful for checking the diarrhoea.

VI. Dyienterio Dianhcoa is a sequel of dysentery, which may perhaps have been
contracted abroad many years previously. The laity, seeking a more elegant term,
often speak of any form of diarrhoea as ** dysentery.'' The characteristic symptoms
here are : (L) A previous history of acute dysentery, or a residence in dysenteric
countries ; (ii.) the tongue is generally characteristic, being very clean, red, and often
sore ; (iii.) the stools vary, but are generally pale, pasty, frothy and easily ferment ;
(iv.) slight errors in diet produce great aggravation of the diarrhoea. The TreatmerU
consists almost entirely in regulating the diet. Only milk, farinaceous food, and
eggs should be allowed ; no meat, vegetables, or fruit. In severe cases the patient
should live entirely on boiled skimmed milk. 4 or more pints a day. Best and warmth
are very important. Bismuth, with or without a little opium, may check the diarrhoea.

VII. NerTons Diarrhcea is a form of diarrhoea which may continue for years ; it
occurs in nervous people and has the following characteristics : (i.) The motions are

§ 822 GHRONIO DIARRH(BA^8PRUE 325

often quite healthy, sometimes liquid, never attended by melana or muons. There it
usually no pain or tenesmus. The diarrhcsa is generally recurring or intermittent,
occurring in the early morning, or when the patient is *' nervous.'* Sometimes it
follows each meal {lienieric diarriiosa). (ii.) It occurs for the most part in females of a
neurotic type, (iii.) Diet seems to produce little or no influence, but the aUacha are
determined by mental emotion or bodily fatigue. A plain but generous diet is called
for ; and the administration of nuz vomica, belladonna, and bromides is often more
efficacious than astringents. Careful search should be made for any source of uterine
or other reflex irritation. Arsenic (niii. Fowler's solution), with meals, is said to be a
specific for lienterio diarrhoea.

The crises of Locomotor Ataxt sometimes take the form of acute diarrhoea, with
or without pain. In Hysteria acute attacks of diarrhoea, with noisy borboiygmi,
may occur, determined in the same way as other hysterical attacks.

Vul. Amyloid Dis«ft9e of the intestines gives rise to a most intractable form of
chronic dianhoea. Indeed, this is the common mode of death in amyloid disease of
the viscera. The characteristics here are : (i.) A history of long-standing purulent
discharge, or of syphilis ; (ii.) great pallor of the skin, accompanied by evidences of
lardaceous disease in the spleen, liver, and kidney ; (iii.) the stools are generally liquid
and extremely offensive, sometimes attended by h»morrhage. The Treatment is
very unsatisfactory. Pernitrate of iron, sulphuric acid, logwood, acetate of lead, may
be tried, and also opium, which does no harm, even when there is amyloid disease of
the kidney, as there is no tendency to ursemia.
The rarer causes of chronic diarrhoea are :

IX. Senile Dlarrhoeft was, I believe, first described by Maclachlan, in his " Diseases
of Old People." It occurs in persons over sixty or seventy, and is very chronic in its
course, but the patient suffers very little. CSareful examination for organic disease
should be made before concluding that the condition is simply senile diarriioea.
Astringents and most other remedies fail to relieve it, and it may exist for many years
without emaciation or danger to life.

X ffineral Poisons, and espesially arsenic and antimony, in small continuous doses
may cause persistent diarrhoea. It was in this way that the celebrated Maybrick case
was discovered.

XL Pancreatic Disease has been associated with diarrhoea. Dr. Bumey Yeo has
described a case of chronic diarrhoea which resisted all treatment until pancreatic
emulsion was administered. The diarrhoea returned when this was stopped, and ceased
again on its administration. It may be assumed that only the chronic forms of pan-
creatic disease (e.g.. Fibroid Pancreatitis) would be attended by this symptom, and
the diarrhoea is probably dependent upon the exoess of fat and undigested muscle
fibre in thefaeces (§181).

§ 222. Xn. Piilosifl or Sprue is a condition met with in the tropics. It is charac-
terised by diarrhoea and other symptoms of congestion of the alimentary canal usually
running a prolonged, and often fatal, course.

The Symptoma consist of (i.) diarrhoea, which is very chronic and continuous, and
attended by pale, copious, and frothy stools ; (ii.) dyspepsia, with distension of the
abdomen and emaciation ; and (iii. ) tenderness of the mouth. At times these symptoms
are exacerbated, and aphthous patches appear on the mucous membrane of the mouth
and pharynx. In the course of time the patient becomes extremely feeble. Any
disease of the intestine, such as dysentery, and any cause of general weakness, pre-
disposes to Sprue. Women are more often affected than men. If untreated, the
disease is usually fatal in one or two years ; even with treatment it may lead to death
in six to ten years. Much depends upon the age of the patient ; in late middle-age
cure is unlikely.

The TreatmerU consists in giving as much rest as possible to the alimentary canal.
The patient must be put to bed, and kept on a restricted milk diet for six weeks or
more. The patient may gradually return in the course of a few months to ordinary
diet, but meat and coarse vegetables must be taken only seldom, even after recovery.
When milk disagrees, after trying condensed and peptonised milk, raw meat juice may
be tried for a time. It is important not to give large quantities per diem, however
much the patient may complain of hunger. To begin with only 2 pints of milk should

326 THE INTESTINAL CANAL [ § 228

be allowed. This may bo increased, when the mouth is not tender, to 5 or 6 pints a day,
in the conrse of two months. The juice of raw fruits, especially strawberries, has been
recommended. Alcohol is injurious.

§ 223. Tenesmus literally means straining at stool (rctVo), to strain
or stretch) ; but in its widest sense it may be taken to mean any local
rectal sensation of " bearing down " which results either in a constant
desire to go to stool, or a straining when at stool. The latter may lead
to prolapse of the rectum, especially in childien. Diarrhoea is always
attended by more or less tenesmus, but tenesmus is not alwayB attended
by diarrhoea. (1) Ascertain if the tenesmus is accompanied by diarrhoea —
t.e., are the motions frequent and liquid ? If so, refer to the section on
Diarrhoea, § 217. (2) Particular attention should also be paid to the
shape and consistence of the motions. (3) Examine locally for any anal
or rectal condition such as fissures, piles, polypi, or ulcers. All the pelvic
organs should also be very thoroughly investigated, especially in women,
in whom the symptom is commoner than in men.

Causes, — Tenesmus (not necessarily accompanied by diarrhoea) may
arise from four groups of causes :

1. Various conditions of the anus — pruritus, eczema, or fissure — may
be overlooked for a long time. Piles also, if internal, may be difficult to
detect, but streaks of bright blood will appear in the motions from time
to time in that case.

2. Various rectal coNDrriONS, especially stricture or ulceration. The
former (usually of syphilitic origin) is attended by tape-like stools ; the
latter is attended by pus or blood, or both. Prolonged use of purgatives,
or the constant use of the glycerine enema may result in straining at stool
and prolapse of the rectum. Proctitis (inflammation of the rectum and
anus) is another cause. In the aged, we should alwayB suspect cancer of
the rectum, although this is usually attended by actual diarrhoea.

3. Pressure on, or irritation of, the rectum prom without, such as
may be caused by chronic congestion, version, or other disease of the
uterus. These in women, and congestion or new growth of the prostate
in men, are both very common causes. Any bladder disease, such as
stone — a frequent cause of tenesmus in children, and apt to result in
prolapse of the rectum — or new growths or chronic cystitis may cause this
distressing condition. Ischio-rectal abscess, pelvic hsematocele, and
various ovarian and Fallopian tube lesions are all apt to cause tenes-
mus. The catamenial period may be attended by a certain amoimt of
tenesmus.

4. In hysterical and nervous subjects any fright or other emotion
may at once determine tenesmus, which is spoken of by the patient as
" diarrhoea." In tabes dorsalis the " rectal crises " may take the form of
tenesmus.

Treatment, — The indications are (1) the removal of the cause, the treat-
ment of piles and other causal conditions being found elsewhere ; (2) the
relief of any local congestion or irritation of the rectum. Fissure may

S 824 ] BLOOD IN THE STOOLS 327

require antisyphilitic remedies. In any case, morphia, belladonna, or
hydrochlorate of cocaine in the form either of suppositories or enemata
will relieve the distress from which the patient suffers.

§ 224. Blood in the Stools is met with, as we have seen, in dysentery
and some cases of simple diarrhoea ; but it may be met with unassociated
with the latter. The presence of blood in the stools may be recognised
by the reddening of the water in which the stool is placed, or by the
spectroscope. Clinically, blood in the stools may present two widely
different characters : (a) When the blood is of bright crimson colour it
indicates either that the bleeding comes from the rectum or the lower
part of the large bowel ; or, if it comes from the upper part of the intestinal
canal, that it is too large in amount to be acted upon by the intestinal
secretion, (b) MeUena (tar-coloured stools) is met with when haemorrhage
in moderate quantity has taken place in the stomach or the upper part
of the alimentary tract, when the digestive fluids of the stomach and
intestine acting on the blood give it this tarry colour. The causes of these
two conditions may to some extent be interchangeable, for what will
produce .a large hsemorrhage at one time may at another produce only a
little.

(a) BrU^t Bed Blood may be due to the lesions of the lower part of
the alimentary canal. Of these, 1, 2, 3, 5, and 7 are referable to the anus
or rectum, and may generally be discovered on local examination.

1. HiBMOBRHOiDS, or PiLES, are undoubtedly the commonest cause of
blood in the stools. The blood is generally met with in streaks only,
but the quantity may at other times be very large. This condition is fully
described below, § 225.

2. Fissure of the Anus may also produce streaks of blood. It is a
not infrequent condition, and is recognised by the excruciating pain
during and after defseoation. The irritation it causes may give rise to a
variety of false diarrhoea. The fissure can always be seen by careful
examination.

3. Reotal Ulcers may give rise to streaks of bright blood in greater
or less quantity, mixed with pus and mucus. They are usually of syphi-
litic, cancerous, or dysenteric origin, and can frequently be felt by digital
examination (§ 221).

4. A discharge of blood-stained mucus, coming on somewhat suddenly
in an infant, is highly suggestive of Intestinal Intussusception, which
is one of the causes of acute obstruction (§ 228).

5. Rectal Polypi are met with chiefly in children.

6. Typhoid and Tuberculous Ulceration of the small intestine
sometimes produce very profuse discharges of bright red blood, which
comes from the lower end of the small intestine. Other evidences of these
affections are present.

7. BiLHARZiA HiBMATOBTA causes hematuria, and also gives rise to
fleshy masses in the rectal mucous membrane, resembling piles. The ova

328 THE INTESTINAL CANAL [ { 226

are veiy characteristic, and can be detected in the fsBoes (§§ 215 and 300).
It occurs in persons who have been in Egypt or South Africa.

8. Various General Blood Conditions may give rise to hsemorrhage
coming from the rectum or elsewhere in the alimentary canal in varying
amount. This occurs in purpura, scurvy, hsemorrhagic forms of the specific
fevers, acute yellow atrophy of the liver, and leuksemia.

(b) Metona {tarry stools) is met with when bleeding takes place from fhe
stomach, or high up in the alimentary tract in moderate quantity. Its
causes are as follows :

1. When coming from the stomach, it may be associated with profuse
hcBmaUmesis (§ 192) ; the commonest causes of hsematemesis are gastric
ulcer and hepatic cirrhosis.

2. Portal Obstruction (§ 2d«3) is one of the most frequent causes of
melfiena, especiaUy that form due to alcoholic cirrhosis of the atrophic
variety. It may also occur with advanced cardiac disease. In either
case the hsemorrhage in these circumstances is a natural safety-valve, and
gives relief to the engorged state of the portal circulation.

3. Cancerous, Tuberculous, and other Ulcerations of the small
intestine (see §§ 218 and 221), and lardaceous disease of the bowel may
also produce melsena. Colitis may cause traces of occult blood.

4. The General Blood Conditions above named, when the hsamor-
rhage is small in amount, are attended by tarry instead of bright red stools.
Melmna neonatorum is a rare condition in which there is a passage of blood
in new-bom children. Nothing is known as to its cause. It may prove
fatal or disappear, leaving the child ansemic but otherwise none the worse.

5. The Anktlostomum Duodenale (ankylostomiasis) is a frequent
cause of profuse mel«»i4b in Eg3^t and other foreign countries (§§ 215, 411).

The Treatment of melsena should be directed to the cause, but the
general principles are those laid down for hsematemesis (§ 192). Tur-
pentine (10 minims capsule), lead acetate, and opium are recommended.
Suprarenal gland has recently been advocated as a remedy. Ankylos-
tomum b readily destroyed by thymol (§ 411). Until recently melaena
neonatorum defied all treatment, but many cases have now been reported
in which the subcutaneous injection of serum has stopped the hsemorrhage.
Human serum is best, but if not available fresh horse serum or anti-
diphtheritic serum may be used. The initial dose is 5 c.c, but this may
have to be repeated until 60 to 70 c.c. have been given.

§ 225. Hssmorrhoids, or Piles, consist of a varicose condition of the
rectal veins. This varicosity forms a swelling of variable size, which may
be altogether within the anus (internal piles), or partly internal and partly
external. Internal piles may in some cases be seen, when the patient
''bears down" as small purple swellings just protruding from the
sphincter; in other cases internal piles are discovered only on digital
examination of the rectum.

Symftoms, — (1) Streaks of hright red blood occur in the stools, and
sometimes as much as \ pint of blood may be passed at one time. (2) There

§ 226 ] HMM0RRH0ID8 320

is pain on defsecation, the pain continuing for some time after the passage
of a stool. When a pile becomes inflamed, or strangulated by the
sphincter, severe pain and discomfort is experienced, and the patient may
have to remain in bed for days. Pain may be referred to other parts of the
body — e.^., to the testicles, bladder, or loins. (3) Constipation nearly
always accompanies piles, due partly to mechanical obstruction, and
partly to the pain caused by defcecation. (4) In severe cases constitutional
symptoms are developed, such as lassitude, irritability, headache, faintness,
and later on anaemia, from loss of blood.

Etiology, — (1) Portal obstruction is itself a cause of piles, and in all
marked cases we should seek for the other symptoms of this lesion (§ 233).
(2) Habitual constipation, however, is imdoubtedly the most common
cause of haemorrhoids, particularly in women, who in early life are so apt
to contract this habit. (3) Alcohol, especially in the form of malt liquors,
with excess of sugar, causes portal congestion, and thus becomes a source
of piles. Alcohol in any form aggravates the condition. (4) Sedentary
occupations and deficient exercise also produce piles. (5) Various local
conditions, such as sitting on soft cushions which constrict the inferior
hsemorrhoidal veins, uterine displacements, pelvic and other tumours, are
all potent causes of haemorrhoids.

Prognosis. — ^Haemorrhoids are not usually regarded as serious, but they
may be extremely troublesome, partly by the constant loss of blood,
partly by their liability to repeated attacks of inflammation, and partly
by the pain they cause.

Treatment. — Much may be done by three simple means : (1) The avoid-
ance of alcohol (especially malt liquors) and sugar ; (2) keeping the piles
scrupulously clean ; and (3) the bowels regularly and loosely open. Rich
food and other causes of hepatic congestion must be forbidden. Hydra-
gogue purgatives are best — such as Mist. Alba, Hunyadi, or Carlsbad
waters every morning, or confecfc. sulph., or sennae, with ah occasional
cholagogue at night. Regular exercise is desirable. Local applications
should be of the simplest kind . The old-fashioned gall and opium ointment
is now very properly replaced by hamamelis, with conium, morphia, or
cocaine for the pain if necessary. Unguentum hamamelidis (B.P.) is an
excellent preparation, and is best applied on a strip of lint inserted within
the anus, and left there ; or a suppository may be employed, containing
1 to 3 grains of hamamelin, and \ grain of morphia if requisite. Inflamed
piles are very painful, and are best treated by warm hip-baths, frequent
bathing, sitting over hot water in a bidet, warm fomentations with opium,
belladonna, or cocaine. Incision may be required, but leeches are better.
For the radical cure, removal by surgical measures is called for in some
cases.

§ 226. Intestinal Worms ^ may giTe rise to no symptoms at alL They are most
frequently met with in children, and may remain undiscoTered until they are found

^ Intestinal myiasis is rare in this country. The ** worms " are the laryie of flies.
For oases with bibliography, see article by Dr. E. A. Cockayne, the Lancet, January 20,
1912.

330 THE INTESTINAL OANAL [ § 2«7

in the stools. The morphology, symptoms, and habitat of the various entozoa are
described in Table XVII., p. 312. Threadworms (Fig. 66) and roundworms (Fig. 67)
are the most common. It usod to be considered that threadworms lived in the colon,
but it is now believed they exist in the caput csBCum, and sometimes in the vermiform
appendix. This fact explains those cases which appear to be cured for a time, but
which continually relapse.

The Symptoms are very indefinite, and consist of : (1) Vague and persistent, though
often paroxysmal, pains in the abdomen ; (2) capricious and sometimes ravenous
appetite, in spite of which the child becomes thin and sallow ; (3) grinding of the
teeth at night, picking of the nose, and other reflex phenomena ; (4) irregularity of the
bowels, or diarrhoea. Threadworms produce intense itching of the anus, and conse-
quently fidgettiness, especially at night. They may wander forwards and cause
vulvitis. In addition to the above symptoms, they may give rise to nervous signs so
severe as to suggest meningitis. Ankylostomum, tricocephalus, bilharzia, and distoma
cause severe anaemia and debility, and are described under anaemia (f 411).

The Prognosis is usually good when the cause is discovered. Occasionally round
worms have led to death from perforation of the bowel ; and they have been found in
the gall-bladder, Eustachian tube, and bronchi.

The Treatment differs for the different worms. For threadworms the best treatment
consists of quassia injections. After an aperient, 1 ounce of powdered quassia to a
pint of boiling water is, when cold, injected slowly into the bowel, and retained as long
as possible. Common salt injections of the same strength may be used nightiy.
The worms are destroyed with two or three such injections. Santonin (1 grain) in a
powder with calomel is very efficacious ; it should be given on alternate dayd for tiiree
doses, followed by castor oil. Where the worm has its habitat high up in the intestine
(as the tapeworm), treatment is conducted in three stages. (1) In order to starve the
parasite by keeping the alimentaiy canal as empty as possible, the patient should have
no food after midday, and at m'g^t or the next morning a purgative must be taken.
This leaves the worm uncovered, and thus readily acted upon by (2) the anthelmintic,
which is given about an hour after purgation. The chief anthelmintic is ext. filicis
liq., 1 drachm. Some recommend 30 minims of spirits of turpentine to be given with
this ; others give kousso (4 drachms) or peUetierine (2 grains of the alkaloid). (3) Two
hours later give calomel with a saline aperient, to eject the worm from the body. The
stools must be examined to see that the head is passed. If only segments are passed
the worm will grow again, and the same treatment will have to be repeated within
three months. For the round worm the specific remedy is santonin, given in 2 grain
doses to a child of three and upwards ; for an adult 5 grains are given. Follow with a
purge. For Ankylostomum Duodenale, see { 411.

§ 2Sn. CoDfltipation is insufficient action of the bowels, or the passage
only of hard, dry, or ball-like masses of fsBces (scybala), independent of
organic disease within or outside the intestinal canal. This source of
fallacy must be carefully excluded before diagnosing a case as one of
simple constipation.

The Sympoms which accompany or result from constipation are suffi-
ciently familiar — at first headache, languor, and depression, followed by
a furred, coated tongue, dyspepsia, sallow or pigmented skin, anaemia,
sleeplessness, and eruptions, for the most part of an urticarial or erythe-
matous nature. The temperature may rise a degree or so in certain con-
ditions from temporary constipation, and I have met with one case where
it went up to 102° F. The retention of hard faecal masses may give rise
t > an alternating diarrhoea, which leads to error in diagnosis . Haemorrhoids
is another consequence of habitual constipation, and a distended ulcerated
colon may result in some subjects. In women, in whom the condition is
far more common than in men, a chronic torpidity of the bowels may

237 ] CONSTIPATION 331

predispose or even lead to uterine disease ; and in both sexes varicose
veins, oedema of the legs, sciatica, especially on the left side, and numbness
of the legs are among its consequences.

For purposes of treatment we may consider the Causes of simple or
uncomplicated cases of constipation under three headings :

(a) Enron of Diet

(i.) Too bland food— «.^., no vegetables, no food with coarse residue,
(ii.) Too dry food — e.g,, deficient fluid ingesta.
(iii.) Too little or poor food, or too great uniformity of diet.

(h) Causes of Defeetive Vermicnlar Action (other than errors of diet).

(i.) Sedentary habits.

(ii.) Advanced age, and other conditions where the general neuro-muscular tone
is poor, as in melancholia, or aneemia.

(iii) Prolonged disregard of calls of nature.

(iv.) Weak abdominal muscles.

(v.) Atony of the intestine, with or without chronic (mucous) colitis (§221, IV.).

(vi.) Diseases of the cord or brain — e.g., cerebral tumour, tabes,
(vii.) Some febrile states,
(viii.) Spasmodic reflex conditions, as from uterine or ovarian diseases.

(ix.) Drugs, such as opium, lead, iron.

(i.) Functional inactivity of the liver (§ 249).
(iL) Profuse vomiting.

(iiL) Excessive loss of fluid by skin or kidneys.

(iv.) Astringents, such as chalk or catechu. Hard waters also act in the same
way.

Treatment, — Chronic constipation is serious in respect of the trouble-
some consequences mentioned above. In its treatment we should first
endeavour to find out the cause. Examine the colon to see if it be dis-
tended ; place one hand at the back, and press it forwards between the
iliac crest and the last rib to meet the other hand, which is placed flat on
the anterior abdominal wall, the patient being in the recumbent position.
An X-ray examination assists in deciding the presence or absence of
mechanical obstruction, and the position of chief delay in the passage of
the intestinal contents (§ 198). Having excluded local causes by a thorough
examination, we should consider the various causes above mentioned.
The treatment of constipation comes under six headings.

(1) Dietetic Treatment, — Increase the amount of fluid taken — e,g,, by
sipping a tumbler of cold water slowly whilst dressing in the morning and
undressing at night. Avoid large quantities of milk or hard water.
Coarse foods should be eaten which stimulate the intestinal wall, such as
oatmeal, wholemeal, or brown bread, green and raw vegetables, onions,
figs, prunes, and ripe fruits. A teaspoonful or tablespoonful of salad-oil
at meal-times wUl often be very efficacious in cases due to deficient
intestinal secretion. Various liquid paraffin preparations are now on the
market ; they act as lubricants, assisting the passage of the intestinal
contents. Agar-agar has also been used with good effect in some cases.
(2) Inculcate regular habits, even when there is no inclination to go to stool.
Psychotherapy may also be employed. (3) Active exercise is advisable.

332 THE INTESTINAL CANAL [ § 887

excepting where uterine or ovarian irritation is in operation. A systematic
exercise may be practised by lying flat upon the back and rising from a
recumbent position without the aid of the arms ten or a dozen times
each morning and evening. Other exercises are now taught which have
the object of strengthening the abdominal muscles. Electrical treatment
probably acts somewhat similarly, and also stimulates the muscle of the
intestinal canal. (4) Abdominal massage is often useful. Gently " roll-
ing " the abdominal wall, or rolling a 7-pound shot-ball over the abdomen
in the direction of the hands of the clock. (5) Drugs, — For occasional
constipation, aloes with the evening meal and a seidlitz-powder in the
morning are the most harmless. Calomel or other mercurial preparations
should not be given habitually, but may be taken once a week for a few
weeks. A useful vegetable pill is pil. col. co., pil. rhei co., 55 gr. i., ext.
hyoscyami, gr. J ; two at bedtime. Another good formula is Tr. Nuc. Vom.,
Tr. Belladonna, aa mv., Tr. Hyoscyam. ; ll\x., Ext. Case. Sag. liq. ad 3i.
Belladonna and nux vomica in small doses undoubtedly promote ver-
micular action ; the former is especially useful for women with pelvic
irritation. A two-months' course of cascara sagrada, graduating the dose
to the individual, will often break through a vicious habit of constipation.
Jalap, elaterium, scammony, and gamboge are useful when drastic pur-
gation is desired. Salines given daily for some weeks will often re-establish
the functions of a torpid intestine (F. 46). These may be given in the
form of the mineral waters, such as Carlsbad, which contains 13 grains of
sulphate of soda to the tumbler, with alkalies (dose, one or two tumblers
twice daily) ; Friedrichshall, which contains 60 grains of the sulphates
of magnesia and soda with alkalies (dose, half a tumblerful daily) ;
Hunyadi water, which contains 200 grains of sulphates of soda and
magnesia with alkalies (dose, quarter to half a tumbler). All of these are
best given on an empty stomach (F. 57, 88, and 90 are also useful). An
excellent aperient for children is cascara and maltine mixed together in
the proportion of 10 to 20 minims of the ext. case, sagrad. liq. to the
teaspoonful of maltine. (6) Enemata are useful in conditions of atony
of the descending colon, and pouched rectum; it must be remembered
that they do not empty the small intestine. The ordinary soap enema of
1 or 2 pints of soapy water may be used. Half an ounce of glycerine is a
very effective enema, but it should not be used longer than a few weeks,
for it produces an irritable condition of the rectum. In cases of very
prolonged constipation which resist all other means, I am in the habit of
prescribing i to J pint of olive oil as an enema every night. If this be
injected very slowly, it is retained, and after a course of one or two weeks
it is wonderful how regularly the bowel resumes its functions.

ffinohspnmg'f Dif0M0 is a condition of atony and dilatation of the colon of con-
genital origin. The cause is unknown.

Symptoms. — There is obstinate constipation, starting in the first weeks of life, and
subsequently tympanites with visible peristalsis, auto-intoxication and emaciation.
If early childhood is survived, complications such as peritonitis, volvulus and intestinal
obstruction may ensue. The disease is fatal in the absence of treatment.

§ 228 ] ACUTE INTESTINAL 0B8TBUCT10N 333

The Dioffnoeis can only be made by the history and obvious signs of a distended
colon. A similar condition may be acquired by prolonged bad habits, but this is not
HirBohsprung*8 disease.

Treatment, — ^Attend to the diet and stimulate the intestinal muscle with strychnine,
massage and electricity. Lai^ enemata may be tried. Operation may be necessary —
" short-circuiting " by Lane's method, with or without extirpation of the large bowel.

The fotient comflains o/*8UDDBN stoppage of the bowels with inability
to 'pass even flatus, abdominal pain, and vomitino which gradually becomes
stercaraceaus ; his pulse is rapid, and there is a tendency to collapse. The
case is probably one of Acute Intestinal Obstruction.

§ 22S. Acate InteBtmal Obitnictioii is one of the most serious medical
or surgical emergencies to which a medical man can be summoned.

The symptoms common to all forms of acute obstruction are (1) complete
constipation, not even fl4Uus being passed. (2) The pain is at first
paroxysmal, referred to the umbilicus, though it becomes continuous
later on. There is not usually much tenderness. (3) The vomiting comes
on earlier, is more urgent, and becomes more rapidly stercoraceous in
proportion as the obstruction has taken place high up in the intestines.
(4) Abdominal distension is generally present, and this may be one-sided,
so giving us a clue to the position of the obstruction. (5) Constitutional
symptoms gradually supervene, with prostration and a thready, rapid
pulse. These also are more urgent when the small intestine is involved.
The urine is diminished in proportion as the obstruction is near the
stomach, for then the vomiting is more urgent.

Diagnosis of Acute Intestinal Obstruction, — When summoned to a case
presenting these three symptoms — stoppage of the bowels, acute abdominal
pain, and vomiting — the first step is to identify the case as one of acute
obstruction. In colic (renal, hepatic, or intestinal) all of these three
symptoms may be present, but the patient's general condition is not so
serious, and the bowels are readily relieved by purgatives or enemata.
Moreover, the position of the pain in renal and hepatic colic is character-
btic (see § 172). In acute peritonitis there is great tenderness over the
abdomen, thoracic respiration, and some fever (see also § 170). But when
there is perforation into the peritoneum collapse is present, at first without
fever, and perforation is diagnosed with difficulty only by (i.) the passage
of wind by the bowel ; (ii.) the collapse being much greater even than that
in acute obstruction ; and (iii.) a possible history of the condition which
has resulted in perforation or rupture (consult also § 169). It is sometimes
impossible to diagnose these two conditions, and an exploratory operation
should be undertaken without delay.

Causes of Intestinal Obstruction, — ^It is of some importance to ascertain
the cause, for the prognosb and treatment difEer somewhat in each case,
(a) In acute intestinal obstruction, in which the symptoms come on
suddenly in a person previously healthy, there are three common causes :
(I.) External hernia ; (II.) intussusception ; (III.) internal strangulation.
(6) Sometimes, however, acute will supervene on chronic obstruction, and

334 THE INTESTINAL CANAL [ § 228

the common causes of chronic obstruction (§ 229) are four in number :
(I.) Malignant stricture of the bowel ; (II.) simple stricture ; (III.) pressure
of a tumour ; and (IV.) dilatation of the bowel.

Features s fecial to the several causes of acute intestinal obstruction.

I. External Hernia is known by the presence of a tumour in the
femoral, inguinal, or umbilical region. No impulse on coughing is present.
Obturator hernia is very rare, and is usually only discovered at the time
of operation.

II; Intussusception, or invagination of the bowel, is by far the
commonest cause in childhood. According to Brunton, it is a cause of
43 per cent of all cases of obstruction. True intussusception is always
from the bowel above into the part below, and in more than half of the
cases the lower part of the ileum becomes invaginated into the cfiBcum.
In a third of the cases some other part of the ileum, and in about one-eighth
some part of the colon, is implicated. The invaginated portion slowly
sloughs, the two edges may be welded together, the slough may pass
about the eighth or tenth day ; thus spontaneous recovery may occur,
though this is relatively rare. Death from perforation and collapse is
more usual unless the case is dealt with surgically. Intussusception is
known by (i.) severe tenesmus ; (ii.) a rectal discharge of hlood and mucus ;
(iii.) a sausage-shaped tumour may be felt, altering in position, on pal-
pating the abdomen, and in extreme cases the invaginated portion of bowel
is felt per rectum ; and (iv.) the patient is a child, usually under two years
of age.

III. Internal Hernia or Strangulation — e.g., by bands of adhesion
— is known by (i.) the urgency of the symptoms ; (ii.) the patient is an
adult man, with (iii.) a history of old peritonitis. Volvulus (or twisting
of the bowel) may be indistinguishable from the preceding — indeed, it
practically results in strangulation — but (i.) it occurs in men over forty,
usually with a history of chronic constipation ; (ii.) abdominal distension
may be great ; (iii.) sometimes a tumour is felt over the sigmoid flexure, the
usual site of volvulus.

Internal strangulation may also arise from (1) adhesion of the end of
the appendix vermiformis through which a knuckle of the bowel gets
nipped. (2) Agglutinations of the bowel. This is a cause of 3J per cent,
of the cases of acute obstruction. (3) Congenital deficiencies in the
mesentery or bowel, or the foramen of Winslow.^

Tho rarer causes of acute obstruction are three in number :

IV. Impaction in the Bowel of a large Gall-stone. This is not so rare as might
be supposed, and Dr. Murchison was able, without much difficulty, he stated, to collect
thirty -four cases. A largo gall-stone escapes from the gall- bladder by ulceration into
tho bowel. The obstruction is high up in the small intestine, and consequently (1) tho
pain and constitutional symptoms are of extreme severity, and of very sudden onset.

^ The rarer conditions are connected with congenital malformations. For instance,
an interesting case of a patent Mockers diverticulum into which the posterior wall of
the ileum became intussusceptod, forming an umbilical tumour, in a male child, set.
six weeks, is published by Dr. Leonard Guthrie in Pediatrics, July 1, 1896, voL iL

} 828 ] ACUTE INTESTINAL OBSTRUCTION 335

(2) The patient U usually a femalo (four females to one male.) at or beyond middlo ago.

(3) There may be a history of biliary colic, and in all cases there is a history of localised
peritonitis some weeks or months before the seizure. (4) The symptoms may intermit,
from the stone shifting its position.

V. Obstmetion of the bowel may sometimes be due to an Extravasation of
Blood into the ooatfi of the intestine. It ooours only in purpura, hsBmophilia, and
other blood disorders. Such cases are rocognised by evidences of hsemorrhago. in
other positions — mel»na, epistaxis, purpura.

VI. Among the still rarer causes of obstruction may bo mentioned masses of round
worms (Trousseau), impaction of too much cellulose, orange-peel, etc., hair-balls,
concretions of ammonio-phosphate of magnesium (a frequent cause in horses, though
rjkre in man), and other foreign bodies in the intestine.

Clinical Investigation and Diagnosis of the Cause of Obstruction. — If
the case occur in a child, and there is a history of diarrhoea for the past
few days, it is almost certainly intussusception ; in an old person suspect
rectal stricture, impacted fseces, or volvulus ; in a young adult suspect
strangulation or hernia. If the vomiting come on early and is urgent, it
points to a tight constriction high up in the intestinal tube. So also after
the onset of obstruction high up there may be a movement of the bowels.
If the distension is chiefly in the centre of the abdomen, the obstruction is
probably above the ileo-csecal valve ; if it is chiefly in the flanks, the
obstruction is below the valve ; if more in the right than in the left flank,
the obstruction is probably in the splenic flexure.

When called to such a case, first examine for swelling in the positions
of external hemise. If the abdomen be distended, and present visible
waves of peristalsis, inquire as to the causes of chronic obstruction (infra),
as the case is probably an acute supervening upon a chronic obstruction.
Always examine per rectum, for in acute intussusception the invaginated
part of the bowel may be felt per rectum, and there may be a discharge of
blood and mucus ; or a stricture or other cause of chronic obstruction mav
thus be discovered. Next inquire into the past history — e.g., for peri-
tonitis (as this is a cause of internal strangulation), or for appendicitis or
hepatic colic. Then examine the abdomen by palpation and percussion
for tumour or tenderness. If the abdomen is distended only on one side,
the site of the obstruction may be localised.

Prognosis. — The prognosis of obstruction of the bowels is always very
serious. Death occurs in the natural course either from (1) gangrene
and rupture of the bowel, or (2) exhaustion and collapse. The prognosis
almost entirely depends in the present day upon the stage at which the case
comes under notice, and the treatment adopted. All the acute cases require
early surgical interference, and a surgeon should be summoned at once.
The success and justification of such diagnostic operations form one of the
chief triumphs of modern surgery. As regards the Causes, obstruction
from a gall-stone is perhaps the most serious, then intussusception, then
internal strangulation. Among the gradual causes, carcinoma of the
bowel gives the gravest prognosis, and paralysis the most favourable.
Cases in which the obstruction is high up are less favourable than those
in the large bowel.

336 THE INTESTINAL OANAL [ §

Treatment. — Acute intestinal obstruction is one of those serious con-
ditions that demand the resources of both a physician and a surgeon,
who should jointly undertake the management of a case. The indica-
tions are (1) to ascertain the cause ; (2) to endeavour to remove the
obstruction ; and (3) in the meantime to support the strength and relieve
the pain by controlling the peristalsis upon which it depends. Enemata
may be given in all cases ; purgatives should be avoided. Warmth is
applied to the abdomen in the form of hot fomentations, turpentine, bella-
donna, or opiimi stupes. If there are signs of peritonitis, cold is said to
be more efficacious. The question of the administration of opiimi is
debated (see Appendicitis), but generally speaking for the relief of the pain
opium may be given as soon as the diagnosis is certain. The diet should
consist of fluids, such as iced milk, beef -tea, and stimulants, given in small
quantities, and frequently.

In external hernia, after a warm bath, it is best to proceed at once to
operation. In intussusception some mild cases have a tendency to spon-
taneous recovery. Some surgeons reconmiend that an attempt should be
made to reduce it by injections of warm saline or olive oil, but it is better
to proceed at once to laparotomy. In irUemal strangulation or twisting it is
best to operate without delay if an injection does not relieve and we are
certain of the diagnosis. In cases of recovery without operation there
has probably been a simple volvulus. But death almost always occurs in
cases of internal strangulation if unrelieved. Manipulation, and inflating
the bowel by means of bellows, have been suggested, but there is consider-
able risk attending these procedures. In impacted gall-stone, the progress
is so rapid towards a fatal issue that operation, if undertaken, must be
done immediately. The same remark applies to other foreign substances
in the intestine.

The patient complains of constipation progressively increasing, abdo-
minal PAIN, and from time to time vomiting ; there is general iU-health.
The case is one of Chronic Intestinal Obstruction.

§ 229. In Chronic Intestinal Obstruction (1) the abdominal pain is
generalised, intermittent, and of increasing severity. (2) There is con-
stipation, or a history of alternate constipation and diarrhcea culminating
in complete stoppage ; and (3) abdominal distension in most cases, and
peristalsis in some, may be visible. The chief causes of this condition are
four in number :

I. Malignant Stricture by new growth in the wall of the bowel —
e.g., cancer. Its most common situations are the colon, especially the
sigmoid flexure, and the rectum. This cause of obstruction may be
recognised by (1) the presence of a tumour or stricture which may be felt
on examination per rectum, and the distension of the abdomen being most
marked in the flanks. When the tumour is situated higher up than the
sigmoid flexure, it may generally be felt through the abdominal wall ;
and when situated in the sigmoid flexure, it may be inspected by a sig-

i 829 ] OHBONIC INTESTINAL OBSTRUCTION 337

moidoscope. (2) When the sigmoid flexure or rectum is afEected, the
illness is often preceded by sciatica on the left side. (3) There are can-
cerous cachexia, the age of the patient, and perhaps hsemorrhage and foetid
discharge to aid in the diagnosis.

II. Simple — i.e., Non-Malignant Stricjturb of the intestine may
arise in consequence of dysenteric, syphilitic, or other ulceration, either
in the colon or in the rectum. An ulcer alone is capable of producing
symptoms of obstruction. This cause is recognised by (1) the absence
of a tumour, and (2) a previous history of dysentery (perhaps only a mild
attack), and residence in a tropical climate ; or a history of sjrphilis, with
a rectal discharge. Syphilitic stricture is rare, except between the sigmoid
flexure and the anus.

in. Pbbssure on the Bowel by a Tumour or an enlargement of
some viscus such as the uterus. This cause is recognised by the physical
signs of tumour or enlargement respectively.

rV. Dilatation op the Bowel from paralysis of its coats. This is
chiefly met with in the aged. It is differentiated from the other causes
chiefly by (1) the absence of cachexia, tumour, emaciation, or other
symptoms of the preceding causes, and an absence of a history of syphilis
or dysentery. (2) The gradual formation of a soft faecal tumour, situated
in the descending colon. The Diagnosis of these causes is also discussed in
§228.

v. Chbonio PBRiroNins ({ 176) causes a matting together of the intestines, and
intestinal obstruction may result. Cancerous peritonitis is attended by much pain
and the effusion of much fluid ; but in tuberculous peritonitis there are mostly
adhesions, less pain, and less fluid.

VI. Chbonio Inttjssuscbption is thus known : (1) It occurs usually in children ;
(2) tenesmus is present ; (3) a tumour may be felt with characters similar to that met
with in acute intussusception ; and (4) there is usually no marked distension (see also
Aoute Intussusception above).

VII. Hirschsprung's disease ({ 227).

Prognosis, — In all forms of chronic intestinal obstruction the symptoms
of acute obstruction are apt at any time to supervene, from impaction of
fsBces above the narrowing lumen of the gut, but apart from this the
prospect differs considerably in the various causes. A cancerous stricture
is the most, a dilated colon the least, serious. Syphilitic stricture may be
relieved by iodides ; dysenteric stricture is much graver, and irremediable.
The course of a tumour varies with its nature. Chronic intussusception
may spontaneously resolve, the invaginated part sloughing off and being
passed by the rectum, but the outlook is always grave.

Treatment. — In most of the cases of chronic intestinal obstruction,
surgical procedure is ultimately necessary, but at first the treatment con-
sists in watching the patient until a diagnosis can be formed with as much
accuracy as possible, and in giving digestible food, preferably such as
leaves but little residue, the pain being relieved by opium and external
applications (hot fomentations with turpentine or opium). In atony of

the bowel, if oil enemata and other medicinal treatment fail, the faeces

338 THE INTESTINAL OANAL [ § 288

may require to be removed by mechanical means (scooped out). For
simple stricture of the rectum gradual dilatation by bougies may be tried.
In chronic intussusception operation is advisable. In cancerous stricture^
an operation may prolong life by the formation of an artificial anus, and
the longer the operation is delayed, the worse is the prognosis. It should
never be delayed until vomiting has commenced. In some cases the bowel
has been resected with success.

^ For Treatment of Canoer, see § 415.

CHAPTER XII

THE LIVER

We still remain in comparative ignorance of the functional disorders of
the liver, but the structural diseases lend themselves more readily to
physical examination and medical diagnosis. The fact that the liver is
capable of containing a fourth of the blood in the body is sufficient proof
of its importance. All the blood passing from the stomach and intestines
circulates through the liver, after which it joins the general circulation
considerably altered in its composition. Experimental researches show
that the liver is concerned in the manufacture of urea or the antecedents
of urea. Degeneration or destruction of the hepatic cells is attended by
a diminution in the quantity of urea excreted, and the amount of urea in
the urine may be taken as a valuable prognostic guide in many hepatic
disorders. The metamorphosis of the products of digestion in the course
of their elaboration into urea is therefore one of the functions, probably the
chief function, of the liver. Another important function of the liver is the
manufacture of glycogen ; the third and least important function is the
secretion of bile.

PART A, SYMPTOM ATOLOQY,

The sjonptoms due to disorders of the liver are not so clearly defined
as those of cardiac or pulmonary diseases. The cardinal symptoms of
structural disease of the liver are pain in the hepatic region, jaundice,
and a group of symptoms due to portal obstruction, which include
Ascites. When the liver cells become gradually destroyed, as in cirrhosis,
serious disturbance of the general health ensues, and in the later stages
of that and of some other hepatic disorders lethargy passing into coma
supervenes. The chief symptom oi functional derangement of the liver is,
according to Murchison, an excess of lithates in the urine, lithuria, conse-
quent on an excess of lithic or uric acid in the blood (lithsemia). How far
lithsemia is really due to hepatic disorder is still a debated point (§ 249) ;
it may certainly arise in other ways. Functional derangement of the
liver is always attended by depression, which may amount to hypo-
chondriasis, and vague digestive disturbances.

§ 280. Pain and Tenderness over the liver are very marked in peri-
hepatitis and any other condition in which the capsule is involved,

339

340 THE LIVER [§281

and sometimes radiates upwards towards the right scapula. The onset
of pain in the course of a liver complaint may therefore be of consider-
able importance ; for example, in hydatid of the liver, the natural course
of which is painless, it would point to a danger of rupture of the cyst.
When the upper surface of the liver is involved, the pain is very often
referred to the right shoulder ; it is, indeed, a symptom of phrenic (diaphrag-
matic) irritation. The most severe form of pain, however, is that which
occurs in connection with the passage of gall-stones {biliary cdic). In
a considerable number of hepatic disorders pain may be completely absent.
There is, however, in many cases of marked disease or enlargement of the
liver a feeling of weight or fulness in that region, accompanied by an
inability to lie on the left side.

Hepatic pain may be simulated by Pleurodynia (rheumatism of the
intercostal muscles), Intercostal Neuralgia, Pleurisy, Dyspepsia, and
various gastric conditions, and by Intestinal or Renal Colic.

§ 281. Janndice is the term applied to the yellow pigmentation of the
skin and other tissues due to the non-elimination of bile. It appears first
in the urine, in which bile pigments and acids may be detected (§ 282),
next in the conjunctivsB, then in the skin universally and uniformly.

Fallacies. — The yellow coloration of the conjunctiva differentiates jaundice from
all similar pigmentations of the skin. (1) Excess of subconjunctival fal may simulate
jaundice, but this is readily distinguished by its unequal distribution. (2) The sallotc-
ness of the skin in chlorotic young women is easily distinguished by the absence of
bilo in the urine and of yellowness of tho oonjunctivaB. (3) The cachexia of
caicinoma, malaria, and certain other forms of visceral disease, is differentiated in
the same way. (4) The hrornin^ of the skin in Addison's disease is hardly likely to be
mistaken for jaundice. (5) Santonin and rhubarb, administered internally, colour tho
urine, but do not give the reaction for bile in that fluid.

Symptoms accompanyithg Jaundice. — (1) Flatulent dyspepsia, and a
bitter taste in the mouth. (2) Pruritus, which may be very troublesome
in some cases ; eruptions, such as xanthelasma, are less common. (3) The
temperature, as a rule, is subnormal, and the pulse slow ; (4) general debility
and emaciation ensue in prolonged cases ; (5) mental depression is usual,
and in severe cases, notably acute yellow atrophy and cirrhosis, cerebral
symptoms such as delirium and coma, may appear towards the end, and
xanthopsy (yellow vision) is sometimes present. (6) Haemorrhages, either
subcutaneous or from mucous membranes, are liable to occur in severe cases.

Recent experiments have shown that jaundice can no longer be divided
into obstructive and non-obstructivej for all jaundice is obstructive,^
nor into hepatogenous and hcematogenouSy since no bile pigments can be
formed when the liver has been removed. Jaundice may be divided
into that due to ezira-hei»atic obitniotion, and that due to intra-hei»atic
obstniction, or toxsemic janndiee. In the latter group the action of the
poison is, first, blood destruction (haemolysis), resulting in increased
formation of bile pigments ; and, secondly, increased viscidity of the bile,
which causes a temporary obstruction and absorption of bile pigments.

^ Stadelmann, '* Der Icterus und seine versohiedenen Formen," Stuttgart, 1891.

§8S1] JAUNDICE 341

Clinically, jaundice due to extra-hepatic obstruction is distinguished by
the colour of the stools, which are pa!e, slate, or clay-coloured, from the
absence of bile in the intestinal canal.

(a) Janndioe due to Extra -hepatie Obstruction may be produced in three
ways — Obstruction within the bile-duct, disease in the wall (II. and III.
below), or pressure outside the bile-ducts.

1. FoRBiON Bodies within the duct, such as (1) gall-stones and in-
spissated gall ; (2) hydatids, round worms, distoma, and other parasites ;

(3) foreign bodies from the bowel.

II. Catarrhal Inflammation of the bile-ducts, usually spreading from
the duodenum. This, which is known as Catarrhal Jaundice, is one of
the commonest forms of jaundice (§ 239).

III. Stricture, or obliteration of the duct owing to (1) congenital
absence ; (2) perihepatitis ; (3) cicatrisation after ulcer of the duodenum ;

(4) ulceration of the bile-duct, which may produce obstruction by the
swelling around, or lead to stricture ; and (5) spasmodic stricture (?).

IV. Tumours pressing on the duct, such as (1) cancer and other tumours
of the Uver ; (2) enlargement of the glands in the transverse fissure of the
liver ; (3) tumours of the stomach, pancreas, kidney, great omentum ;
(4) fsdcal masses in the intestines; (5) pregnant uterus; (6) ovarian
tumours; and occasionally (7) tumours growing from the walls of the
ducts.

{h) Jaundice due to Intra-hepatic Obstruction (Toxsemic Jaundice) may
arise in (1) cirrhosis of the liver ; (2) pneumonia ; (3) other acute specific
fevers, especially tropical fevers, yellow fever, relapsing fever, and pyaemia ;
(4) animal poisons, such as ptomaines or snake- bite ; (5) chemical poisons,
such as phosphorus, mercury, antimony, arsenic, copper, chloroform, and
ether ; (6) acute yellow atrophy of the liver ; (7) protracted constipation.
Jaundice also arises in newly-born children (icterus neonatorum), and in
states of emotion and concussion of the brain, in a manner not understood.

Of these causes gall-stones and catarrhal jaundice are the most common.
To diagnose which cause is in operation : 1. If possible, examine the
F^OES, which are slate or clay-coloured in complete obstruction, and of
normal colour in toxsemic jaimdice. The presence of fat or parasites may
assist in the diagnosis of the cause. But it must be remembered, as
possible fallacies, that the faeces may become stained if mixed with urine :
and that the bile-duct may be only partially obstructed, and enough bile
may thus escape to colour the faeces.

2. Inquire as to the History of the attack. Jaundice coming on
suddenly, especially in a middle-aged female patient previously in good
health, almost invariably indicates obstruction by gall-stones (rare cases
of nervous shock excepted). The intensity of the jaundice varies from
week to week as the stones pass. Jaundice coming on slowly, and ulti-
mately becoming intense, is generally due to a tumour pressing on the
hepatic duct, and is most often seen in association with cancer. A well*
marked jaundice persisting some weeks is almost certainly obstructive.

342 THE LIVER [ §§ 2S2, 2SS

A history of previous temporary attacks points in adult life to gall-stones ;
in youth to " catarrhal jaundice."

3. Examine the hepatic region carefully. If the liver is enlarged,
cancer is the most probable cause ; interstitial hepatitis less commonly.
If ascites be present, the diagnosis rests between cancer and cirrhosis.

4. Inquire as to pain and coNSTrrurioNAL symptoms. Pain of a
spasmodic and severe character accompanies jaundice due to gall-stones
and cancer. It is more constant and gnawing in character in congestion
of the liver and catarrh of the bile-ducts. The temperature is not often
elevated, but it may be so in catarrhal jaundice, jaundice due to poisons
in the blood, pysemic hepatitis, tuberculous affections, and local pus for-
mations, such as inflamed hydatid. Cerebral symptoms are very rarely
present, except when a fatal termination is at hand, unless the jaundice
occurs in the course of pneumonia, fevers, or in that rare disease, acute
yellow atrophy of the liver.

The Prognosis and Treatment of jaundice depend on its causal diseases
(q.v,). The disappearance of bile from the urine indicates that the attack
is coming to an end, though it may be some weeks before the skin clears.
The flatulent dyspepsia and many of the concurrent symptoms may be
relieved by the administration of ox-gall (5 to 10 grains or more) with
meals, together with carminatives. The itching of jaundice is often a
most troublesome symptom, but it can generally be relieved by pilocarpine;

f 282. Ictemi Veonatoram is a mild transitory fonn of jaundice which affects a
very large number (estimated by various observers at from 70 to 90 per cent.*) of
new-bom infants. It appears usually on the second or third day of life, is not generally
veiy intense, and rarely lasts longer than one or two weeks. The f seces are normal in
colour, and apart from the jaundice the infant presents no other symptoms. The
cause of the condition has been the subject of considerable debate, but the question
is almost entirely an academic one, and the reader is referred to systematic works.
The Treatment, if any is required, is the same as that for catarrhal jaundice.

A severer form of the same condition, sometimes erroneously called Icterus Gravis
Neonatorum, occurring during the first week of life, may be due to (1) Congenital
stricture of the bile-ducts by S3rphilitic perihepatitis ; (2) congenital absence of the
duct ; (3) septicaemia ; (4) WinckePs disease (an epidemic form) ; or (5) acute fatty
degeneration of the new-bom (Buhl). The first and second are diagnosed by the
intensity of the jaundice and the absence of bile from the f»oes ; the remainder present
other sjrmptoms, such as haemorrhages, purpuric spots, and (4 and 5) cyanosis.

f 288. OholflBmia (syn. : Acholuric Jaundice) — Symptoms, — There may be no
symptoms ; it is a notable point in connection with the disease that the patients are
often able to go about their work as if they were not the subjects of any abnormality.
Symptoms when present are jaundice, weakness, a degree of anaemia, and splenomegaly,
which may be extreme. These are liable to exacerbations in which the jaundice grows
deeper, the anaemia and weakness more profound, and the general malaise may be
associated with fever and perhaps vomiting. These attacks seem to be especially
determined by cold. Haemorrhages from the gums or stomach or into the retina
are among the rarer symptoms of the disease. The blood changes are very characteris-
tic : there are nucleated red cells even when the anaemia is very slight, great inequality
in the sizes of the individual corpuscles, and predominance of cells showing basophU
stippling. The blood also contains bile, whereas the urine contains only urobilin.
The colour of the faeces is normal.

* These statistics were taken from hospital cases, which wore placed in ciroumstancea
where a better light probably resulted in the detection of the slightest tinging of the
skin*

{ 8S4 ] PH Y8I0AL EXAMINA TION 848

The Etiology is not known. The disease may be congenital or aoquiied. The
fonner ooonis in families, and may be transmitted by affected members of either sex.

The Prognosis of the congenital form is good as regards life, though recovery is not
to be expected. In the acquired form the symptoms are more marked ; the periods
of health between the attacks are short, and the patient seldom lives to old age.

Treaiment is symptomatic. It is important to avoid cold and exposure.

PART B. PHYSICAL EXAMINATION.

The liver lies chiefly in the right hypochondrium ; the left lobe extends
across the epigastrium above the stomach into the left hypochondrium.

The gall-bladder lies below, in contact with, the liver, and is situated
under the ninth right intercostal cartilage (see Figs. 60 and 70).

The routine methods of examination of the liver consist of Inspeotion,
Palpation, and Percussion. Examination by X-rays may assist in the
diagnosis of certain obscure tumours — e.g., hydatid.

§ 284. Luipeotion locally teaches us but little, as a rule, unless the
symmetry of the abdomen as observed from the foot of the bed be altered.
However, the presence or the absence of jaundice should always be noted
in cases of suspected hepatic disease. If slight, it may be noticeable only
in the conjunctivsB and urine. Deficient chest expansion is noticed with
inflammatory disease of the liver. The lower edge of the organ when
enlarged may be seen moving with respiration. X-ray examination may
reveal impaired movement, irregularities, and tumours of the organ. Note
also it there are venous stigmata in the face or enlargement of the veins of
the abdominal wall, such as occur with cirrhosis and portal obstruction.

During Palpation the patient should be placed in the recumbent posture,
and, in order to obtain complete relaxation of the abdominal walls, he may
be asked to ** let lus breath go.'' If this is not sufiicient, the knees should
be drawn up and the shoulders supported. Standing on the right side of
the patient, place the palmar surface of the hand, previously warmed, on
the right side of the abdomen, immediately above the iliac crest, pressing
it flrmly yet gently inwards. The tips of the Angers should be inclined
slightly upwards and inwards towards the median line, and the Ufper
margin of the index finger should be pressed flrmly down, working little by
little upwards towards the costal margin. In this way the upper border
of the index finger, always held perfectly flat, will come in contact with
the margin of the organ if it be enlarged. But if it is not enlarged, the
liver cannot be felt, for it lies altogether beneath the costal margin in the
adult. In young children, however, the liver is proportionately larger in
all its dimensions, and the lower edge normally protrudes beneath the
costal margin. If the liver is enlarged, try to feel its surface by gently
dipping the fingers down. Notice if its surface is smooth (as in fatty
liver) or nodular (as in cancer), or simply rough (" hobnail "). When there
is fluid in the peritoneal cavity, this method of '* dipping " the fingers
(suddenly) is also useful ; but in most cases the finger tips only excite
contraction of the abdominal muscles, and so frustrate our object. The
other fallacies of hepatic enlargement are mentioned under Percussion,

S44 THE U7EB [ j SS6

Note whether any tenderness or irregularity of the surface is present.
Umbilicat«d nodules may be felt in cancer of the liver. Expansile pulsation
of the whole liver ia felt in cardiac disease with tricuspid regurgitation.

The gall-Madder, if enlarged, may be discovered as a round elastic
tumour, projecting beneath the ninth rib, at its junction with the cartilage;

§ 836. Pflnrasnon should be light, so aa to elicit only the superficial or
absolute dulneaa of the oi^an. In percussing the upper margin, start where
there is a good lung note above, and percuss down from rib to rib in the
nipple, mid-axillaty, and scapular lines. Then repeat the process from
space to space. In defining the lower edge, still lighter percui>Bion should
be used, and the examination should proceed from the tympanitic note of

Upper IJ

^. Id the nip

' ■ctpnlarl
VI,VUI,

Znbrss]

the intestine upwards towards the hepatic region. But the more certain
method of detecting the lower edge is by palpation.

Normally, in the nipple line the superficial or absolute hepatic dulnets
commences two filers' breadth below the nipple, and measures 3J to
4 inches, and in a routine examination this is the most important measure-
ment to obtain. The normal boundaries of the liver are given in Fig. 70.

The lower border arches upwards just beneath the right costal margin
and crosses the epigastrium, where the hepatic dulness becomes continuous
with the cardiac dulness. In the mid-sternal line the dulness extends
from J inch above the base of the xiphoid cartilage to about midway
between the umbilicus and the xiphoid, where the lower edge may be felt
by careful palpation when the abdopiinal wall is very lax. Thus the
absolute duluGBs measures on an average about 2 irtches in the mid-vernal
line and 4 inches in the nipple h'ne.

{ 8t6 ] PERCUaSION— ASCITES 345

These landmarks do not indicate the deep dulness of the liver, which is more
difficult, and in most cases less useful, to determine. But in some cases, such as
abscess or hydatid, it is desirable to make out the deep (or relative) dulness of the liver
by heavy percussion. The extreme height of the liver, as thus made out, corresponds
to the fifth rib in the nipple line, seventh space in the mid-axilla, and ninth space in
the scapular lino.

Light Percussion Boundary (the one ordinarily used) gives » "><a 9
the superficial or absolute dulness — i.e., whore the liver is in contact g « fo hi S" «
with the ribs. ^ s jS 2 { d 1

Upper margin situated at the . . . . . . . . 6th; 8th i 10th rib.

Extent of dulness in vertical line . . . . . . 3^ 4 3 inches.

Umavy Psrcussiom Boundary gives the deep or relative dulness gp|^^
where the liver is covered by lung. ^

Upper margin situated at the . . 5th 7th 9th rib.

Extent of dulnees in vertical line . . ..415

4 inches.

Fallacies. — ^The physician should never feel satisfied with mapping out the liver
once only, because the organ may be temporarily affected by many varying con-
ditions, and the percussion boundaries by no means always give us a true index.
Thus the lower edge may be masked by the dulness of the stomach after a fidl meal,
by an accumulation of f sBces in the colon, or by a thickened omentum. Great rigidity
of the muscles, or osdema of the abdominal walls, may also obscure the lower edge of
the liver.

The beginner, by palpating with his finger tips, which excite muscular contraction,
generally fails to make out the lower margin of the liver, even when the organ is
enlarged. By percussing too heavily he fails to get the ahsciuJte dulness.

Apparent diminution of the liver may arise from (i.) dist?nsion of the stomach or
intestines with gas ; (ii.) by contractions of Glisson*s capsule, especially on the under
surftuse, giving rise to puckering or distortion of shape anteriorly ; or (iii.) emphysema
of the lungs, which obscures the upper border very much. Great diminution or abso-
lute loss of the liver dulness, owing to gas in the peritoneal cavity, is a diagnostic
feature of perforation of the stomach or intestine.

Apparent enlargement, when attention is paid solely to the lower edge of the organ,
may be due to a displacement of the liver downwards (i.) by pleuritic effusion, emphy-
sema, or pneumothorax ; (ii.) intrathoracic tumours ; or (iii.) enlargement of the
heart or hydro-pericardium. These and other fallacies may arise from paying attention
solely to the lower edge of the organ ; and, finally, the liver may in rare cases be dropped
or " floating" ** Riedel's lobe " is mentioned under Abdominal Tumours.

§ 236. Flnid in the Peritoneiim (Ascites) is a frequent accompaniment
of some hepatic disorders, and its presence or its absence must always be
carefolly noted. The methods of investigating this important matter have
already been given (§ 184).

AadteB (Dropsy of the Peritoneum) is one of the Evidences of Portal
Olwtractiony and these are more frequently associated with some disease
of the liver than of any other organ. Sometimes they are the only
evidences we have of hepatic disorder.

The Signs of Portal Obstruction are, in the order in which they
appear : (1) A liability to attacks of gastric and intestinal catarrh, as evi-
denced by irritable dyspepsia, and the vomiting of mucus, streaked
perhaps with blood, in the early morning before breakfast. (2) Hcsmor-
rhage, sometimes in very large quantity, from the stomach and the

346 THE LIVER [|8t7

bowels. (3) HcBmorrhoids may occur in other diseases (§ 225), bnt they
are frequently associated with portal obstruction. (4) Attacks of con-
gestion of the Uver. (5) Congestion, and therefore enlargement, of the
spleen, (6) Ascites (see below). (7) Enlargement of the veins of the ab-
dominal wall from the establishment of a collateral circulation. (8) (Edema
of the legs is a secondary and indirect lesult of the pressure of the ascitic
fluid on the large veins within the abdominal cavity. (9) Albumen in the
urine may arise in the same way, or from concurrent disease of the kidney.

AsciTBS, it will be observed, is a late sign of portal obstruction; It has
already been fully described (§ 185), and it will be remembered that its
three principal causes were Cardiac, Hepatic, and Renal disease. (1) In
cardiac disease the ascites will have been preceded by dropsy of the legs ;
(2) in hepatic disease the ascites is the predominating feature, though it
may be followed by dropsy of the legs ; while (3) in renal disorders the
ascites is only part of a dropsy which is general from the outset. Cancer
of the peritoneum may also produce ascites, but here the nodules of cancer
will probably be felt on palpation, and there will be other symptoms of
cancer. Ascites may have to be diagnosed from an ovarian or other
large abdominal cyst, and from fat in the omentum (§ 182).

Portal obstruction, and cousequently ascites, are not present with equal
frequency in all diseases of the liver, and in some they are absent. In
order of frequency the causes are as follows :

(1) CiBRHOsis, or an increase of the interstitial tissue (usually due to
alcohol), is by far the commonest cause of portal obstruction, by producing
pressure upon the minute branches of the portal vein within the liver.

(2) In Cancer of the liver portal obstruction and ascites are fairly
frequent, but they are due not so much to the cancer within the liver as to
the pressure of enlarged glands in the transverse fissure of the liver upon
the portal vein, or to secondary involvement of the peritoneum.

(3) PEBiHEPATrris may occasionally produce constriction of the portal
vein by puckering at the fissure.

(4) Simple Congestion of the liver may be attended by hemorrhoids
and gastric catarrh, but rarely by much ascites.

(5) Fatty and Waxy Liver, Abscess, and Hydatid are hardly ever
attended by portal obstruction.

The other Causes, the Prognosis, and Treatment of Portal Obstruction
have been described under Ascites (§ 185).

In cases of hepatic disease the urine should always be tested for hUe
(§ 282) and for urates (§ 291), sometimes for leucin and tjrosin ; and the
amount of urea may need to be estimated (§ 280).

PART C, DISEASES OF THE LIVER,

§ 287. Roatine Procedure. — ^FiRsr : Ascertain what is the patient's
Leading Symptom, The symptoms of disorder of the liver we discussed
in Part A. — e.g., gastric disturbance, pain (or a feeling of weight or dis-

§«W] ROUTINE PROCEDURE 347

comfort in the hepatic region), or jaundice. If there be severe and
paroxysmal pain, turn first to biliary colic (§ 241).

Sbcoitoly : Learn the History of the patient's illness, eliciting the
facts in chronological order, and in this way ascertain the important
fact whether the disease be acute or chronic^ because disorders of the liver
may be conveniently classified into these two groups.

Thibdly : The Examination of the Liveb must next be made. The
routine method is as follows :

1. Ascertain whether the liver is enlarged or diminished (by percussion
in the nipple line, and abdominal palpation), and whether there is any
fainy tenderness^ or other abnormality.

2. Ascertain whether there be any fluid in the peritoneum (§ 184).

3. Ascertain if there is any jaundice (§ 231), and examine the urine for
bile pigments, lithates, and the diurnal amount of urea.

Classifloation. — ^For clinical purposes, diseases of the liver may be con-
veniently divided into Acute and Chronic Disorders.

If the illness is one of long standing, and has come on insidiously, the
reader should turn to Chronic Diseases o! the liver (§ 248). The acute
diseases will be first described.

AOUTE DISEASES OF THE LIVER.

If the illness has come on more or less suddenly, and is attended by
considerable malaise or other constitutional symptoms, it is one of the
acute diseases of the liver or hUe ducts, probably : 1. Acute Congestion ;
II. Catarrhal Jaundice ; or III. Gall-stones. The less common acute
diseases are : IV. Perihepatitis ; V. Abscess ; and VI. Acute Yellow
Atrophy.

I. The patient complains of fain or discomfort in the hepatic region,
the liver area may be increased, slight jaundice and numerous vagus
dyspeptic symptoms are present, hat there is little or rw fever. The disease
is probably Acute Congestion of the Liver.

§ 238. Acute Congestion of the Liver. — Clinically, there are two kinds of
congestion of the liver — an active or acute congestion, and a passive or
mechanical congestion. Active or arterial congestion (with which we are
now concerned), is usually met with in the form of acute attacks due to
dietetic errors ; though it may sometimes occur as a more subtle and
sometimes latent condition in a subacute or chronic form which eventuates
in cirrhosis. Passive or venous congestion is due to obstructed venous
return (mostly in chronic cardiac or pulmonary disease) ; it is in the
nature of things a chronic process, and will be considered under Chronic
Diseases (§ 255).

Symptoms. — (1) The onset is usually somewhat sudden, after a series
of indiscretions in diet, especially in the matter of alcohol. The patient
complains of pain, or a feeling of weight or uneasiness in the region of
the liver, and he may be imable to lie on the left side. (2) There is

348

THE LIVEB

generally a slight but uniform enlargement of the liver, and some degree
of tenderness. (3) Slight jaundice is present on the second or third day
in the majority of cases, but it is never so intense as in catarrhal jaundice
or gall-stones. The feeces are dark in colour, owing to the presence of bile.
(4) Certain gastro-intestinal symptoms are present — ^nausea, headache,
furred tongue, a bitter taste in the mouth, and flatulence ; the bowels are
usually constipated ; the urine is scanty, high coloured, and deposits lithates
on standing ; and there is usually some depression of spirits and irritability
of temper.

Table XVIII. — Acute Diseases of the Liver.

I. AOUTS CONOBSTION.

II. Catarrhal Jaundice.

in. OAUrSTONBS.

IV. Pbrihbpatitis.

y. Absobss of Liter.

VI. Aoutb Yellow Atro-
phy (very rare).

Jaundice.

Not very great.

Enlargement of the
liver.

Slight increase.

Always present and Sligtit increase,
marked.

Absent.

Generally present.
Very marked.

Liver diminished in size.

ABdtes.

Usually
absent.

Absent.

Very marked in most • Biay be considerable in- , Absent,
cases. crease. I

None unless another cause. , Usually

absent.

Moderate and irregular en- Usually
largement. none.

Absent.

Etiology, — (I) By far the most frequent cause is alcoholic excess.
Constant indulgence in rich foods containing fat, sugars, and spices may
also produce congestion. (2) Residence in hot climates, especially when
associated with malaria and dietetic errors ; but many attribute to the
climate what is really due to alcohol or faulty diet. (3) Suppression of
an habitual discharge, especially bleeding piles or menstruation ; and

(4) dysentery and febrile states are often accompanied by congestion.

(5) Sudden or protracted chill and (6) injury have been mentioned as
causes. An attack of acute congestion may be predisposed to by (i.) the
presence of chronic congestion (§ 255) ; (ii.) previous attacks of malaria ;
(iii.) indolent or sedentary habits.

The Diagnosis is based upon the occurrence of symptoms of gastro-
intestinal disturbance in association with pain and enlargement of the
liver. In perihepatitis the first-named are absent, the pain is much more
acute, and syphilis is probably in operation. The diagnosis from the
other acute hepatic disorders is given in Table XVIII. above. The
symptoms of pleuro-pneumonia at the onset may include jaundice and the
other symptoms of acute congestion of the liver, for which, indeed, this
disease may be mistaken. It is important, therefore, to examine the base
of the right lung in all such cases when associated with jaundice.

§ 299 ] CONGESTION— CAT ARBH A L J A UNPICK 349

Prognosis, — Acute congestion is very apt to recur, especially if the
patient continues his dietetic indiscretions. The intervals between the
attacks become shorter, and the condition is followed by chronic con-
gestion, and, eventually, cirrhosis. An attack of moderate severity rarely
lasts more than a week or two. Unless a condition of cirrhosis is reached
(when enlargement is checked to some extent by the shrinking of the
newly-formed fibrous tissue), the degree of congestion may be fairly
estimated by the amount of enlargement.

Treatment, — The indications are (1) to relieve the congestion of the
portal system, and (2) to correct dietetic errors. To relieve the congestion,
saline purgatives are specially indicated, such as the sulphates of magnesia,
potash, soda, or the bitartrate of potash. Carlsbad, Friedrichshall, or
Hunyadi Janos water should be taken every morning early, and a full dose
of calomel, podophyllin, or pil. hydrarg. at night. In severe cases leeches,
or dry or wet cupping in the region of the liver, may relieve the pain con-
siderably. Leeches are sometimes applied to the margin of the anus, but
this is not always convenient. Murchison recommended ammonium
chloride in doses of 20 grains two or three times a day, to induce free
diaphoresis, and diminish the portal congestion and pain (Formulse 46, 51,
53, and 66 may be useful). Ipecacuanha is in great repute among Indian
physicians, and is given in large doses, as in dysentery (20 to 30 grains
every six or twelve hours), preceded, half an hour before each dose, by
\ grain of opium to prevent vomiting. * For the gastric symptoms, alkalies,
carbonate of magnesia and bismuth are useful. Nitrohydroehloric acid
and nux vomica are useful in convalescence. The diet during the attack
should be of the simplest, consisting at first of 2 pints of milk a day.
Alcohol in any form should be strictly forbidden.

II. The fotient, who is young, has suffered from gastro-intestinal
DiSTURBANCE^br some days or weeks, when jaundice, with clay-coloured
STOOLS, sets in somewhat suddenly, without local fain, and with little or no
enlargement of the liver. The disease is probably Catarrhal Jaundice.

§ 289. Catarrhal Jaundice (Acute Cholangitis) is jaundice due to in-
flammatory swelling of the lining membrane of the bile-ducts, and the
consequent obstruction to the outflow of bile.

Symftoms. — (1) The jaundice is usually of sudden onset, though it is
preceded for a shorter or longer time by signs of gastro-intestinal disorder.
(2) The jaundice is often very intense, but in mild cases the degree corre-
sponds to that of congestion of the liver. It generally begins to subside
in the course of two or three weeks. If it lasts longer, some other cause
(§ 231) should be suspected. (3) The stools are pipe-clay coloured, and the
urine is dark with bile. (4) Nausea and loss of appetite, flatulence, and
constipation are generally present. (5) A feeling of uneasiness or weight
in the hepatic region is usually complained of. There may be slight
enlargement of the liver, the edge being smooth, firm, and tender. The
spleen may be slightly enlarged. (6) There may be slight fever at the

360 THB LIVER [§240

commencement, but it usually subsides before the patient is seen, and the
pulse is abnormally slow.

Etiology, — (1) Extension of inflammation from the stomach and duode-
num along the bile-ducts secondarily to gastric derangement is the most
common cause of catarrhal jaundice. (2) It is by far the commonest
form of jaundice met with in children and young adults. (3) Exposure
to chill. (4) It may be secondary to congestion (§ 238, ante) or cancer.

(5) Catarrhal jaundice frequently follows the passage of a gall-stone.

(6) In the adult gout or gouty conditions are said to predispose.
Diagnosis, — Catarrhal jaundice may have to be diagnosed in an old

person from cancety but in the latter the jaundice comes on slowly, with
pain, and it lasts many months. In gall-stones there is biliary " colic ''
(§ 241). In congestion of the liver the jaundice is less marked, and the fseces
are not day-coloured.

Prognosis, — The disease is never fatal. It usually terminates in a few
weeks, after the gastric disorder has been relieved. The outlook is tm-
favourable only when catarrhal jaundice complicates other maladies, such
as cancer or gall-stones.

Treatmefnt, — Remove any cause of the concurrent gastro-enteritis, and
allay the condition with alkalies, alkaline carbonates, rhubarb, or bismuth.
A brisk mercurial purge, followed by a saline once or twice a week, helps
to relieve the congestion, both of the intestines and the liver. Ox-gall,
creosote, or salol are sometimes useful as intestinal antiseptics. Sodium
salicylate and ammonium chloride (10 grains of each) is very effective.
Rectal injections of one or two pints of water daily (60° to 90° F.), retained
as long as possible, have been recommended to allay any intestinal irrita-
tion. The prescriptions and much of the treatment for Congestion (§ 238)
are applicable.

§ 240. Bpidemio Jaandioe (syaonyms : Weirs Dlaease, Septio Jaundice (Fnenkel),
Infeotive or Febrile Jaundice) resembles a severe transitory form of catarrhal jaundice
occurring epidemically. Cases of what was probably the same disease were first
described by Weiss in 1866.^ In 1886 Professor Weil, of Heidelberg,^ described four
cases of a peculiar form of acute infective disease characterised by jaundice, which
most GJerman authorities regarded as a disease not hitherto observed.

Symptoms, — ^The malady comes on suddenly, with marked prostration, headache,
and sometimes delirium. The muscular pains, especially in the legs, aro among the
most noticeable features, and may obscure the other symptoms. The jaundice
appears on the second or third day, reaches a moderate degree, lasts about fourteen
days, and then disappears gradually. The stools are generally clay-coloured. The
liver is considerably enlarged and tender, the spleen enlarged, and the urine contains
albumen, epithelial casts, and sometimes blood. The temperature reaches 103° or
104° F. on the second or third day, and begins to fall between the sixth and ninth.
Various rashes and occasionally epistaxis have been observed.

Etiology, — ^There seems to be no doubt that the disease is infectious. It has always
occurred in an epidemic form, chiefly amongst men between the ages of fifteen and
thirty, and especially working-men. Most epidemics have occurred in the summer

^ " Zur Kftnntniiw und snr Geschichte der sogenannten Weilschenkrankheitb** Wien,
med, Woch,, 1890, Bd. xL

^ " Ueber eine eigenthumliche, mit Milztumor. Ikterus, und Nephritis einhtrgehende
akute Infeotionakrankheit.** Deut, Archiv fur Klin, Med., vol. xxxix.;i886.

{ 241 j QALL-BTOSBS 3&1

months. The natnre ot the infection is not yet identified, though Jaeger found the
baoillus proteua fluoroscena in the ntine and organs in wveral c&ses. The ssrao
observer found that the ducks and geese about the river in which the affected patients
had bathed were subject to a fatal disease with marked jaundice. ?)r. Wiilism
Hunter points out that a very similar jaundioe can be produced ezperinientally in
dogs by toluylendiamin, in whom it also produces swelling of the spleen and liver,
and nephritis. In both Weil's disease and poisoning by this reagent the duodenum
is frequentiy found to be the seat of oonudorable congestion.

Inferentiaily, the TTtatment of this Epidemic Jaundioe would appear to resemble
that of Catarriial Jaundioe.

m. The -patient, wuaUy an dderly female, it tudderUy seized with
PAKOXYeHS 07 BEVEBE PAIN in the hepoltc region, and in the course of
tvodtK to twenlyfour hours she becomes jaundiced, the stools becoming
day-coloured. The attack is one of Biliary Couo.

§ 841. GaU-StonM and Biliwy Colic. — Gall-stoaes are concretionB which
form in some part of the biliary passages, most commonly in the gall-

¥ig, VI.— ~ChDleataTln Ciyttali. FIb. 72.-4, Ttbosdi, In bundlst of Dsedle-

Uonaooplc appearanM pre- ihaped ciystiJa, and c, LnroiN, iphsiical

MHited by bagmeota of gall- ciyBtalB with cCDCeDtilc marUiV, faund

stODM In ths iBces. Id tlie urine In rare caisa of acute yellow

atroph; ol tbt liver, b, CTSnn (dear sli-

Eldsd iilateal. Is a rata arlnarr depoalt due

to an inborn error ot metaboIUm. It may

form renal oalimH.

blttdder. CHOLELrmiASis is the condition in which gall-stones are
developed. When gall-stoQes move along any of the dacta, they give
rise to Biliary Colic.

GALL-aroKES may vary in size from partjoles hardly larger than a Band-grain to
the size of a golf-ball. When they are solitary, they are round or oval in contour.
It is important to notice the presence of faoets or Battenings of their sorfaoe, caused
by the presBUie of one against the other, beoanse Oum indioates that there haa been
more tjiaa one stone in the gall-bladder or bile-ducts. Their colour varies from a
yellow to a dark brown, and their ohief physioal characteristics are the smooth *' soapy"
saifaoe, the ready way in which they crumble tietweenthe thumb and finger (though
sometimes they are very hatd), and their lightness as compared with renal oalouli.
They generally consist chiefly ^of^oholesterin^miied with a combination of oaloium
and bile pigment, but aro sometimes either pure cholestenn, pure bilirubin, or pure
ealcium carbonate. Strong sulphuric acid when added to cbolesterin crystals gives
a ruby red at the junction. But the apptaraitce of the crystals is the most cbarao-
teristia featore about them, consisting as they do of rectangular plates, broken by
irregular rectangular fractures (Fig. 71).

BIIi4Z7 CoUo. — Symptoms may be absent when the stone is at rest, but
when it b^ns to move (i.) the pain is agonising ; it starts in the epigastrium
and ahoota into the right hypochondriac region towards the spine and up to
the right shoulder, but never passes downwards. The paroxysm is usually

362 THE LIVER [ 1 241

SO severe that the patient is in a state of partial collapse, with vomiting,
hiccough, subnormal temperature, and a quick, weak pulse. Sometimes
there is a*iigoi, and the temperature rises a few degrees. Between the
paroxysms of acute pain there is a constant dull aching and tenderness
over the hepatic region. The attack lasts from a few hours to a few days,
(ii.) The liver may be enlarged, and if a stone becomes impacted in the
hepatic duct the enlargement may be considerable, (iii.) Jaundice usually
appears twelve to twenty-four hours after the paroxysm, and lasts from
a few days to a few weeks. It is most intense when the stone is impacted
in the common duct.

The Symptoms which arise vary somewhat with the position of the gall-
stone (Fig. 73). Thus : (i.) If a stone is impacted in the common dud, there
are biliary colic, marked jaundice, and a distended gall-bladder, and if the

le Id connecUOD wUh tha Ltver

impaction continues the liver becomes enlarged, (ii.) If a gall-stone be
impacted in the neck of the gall-bladder (i.e., in the cystic d^Kt), biliary
colic is present without jaundice. In time the gall-bladder may be dis-
tended with mucus, and form a definite abdominal tumour, (iii.) Stone
impacted in the hepatic duct is rare. It causes biliary colic and jaundice,
but the gall-bladder is not distended, (iv,) Stones occasionally form in
the radicles of the hepatic ducts, and give rise to indefinite B3mipton]s,
sometimes without pain, and usually without jaundice, (v.) Sometimes
small particles of cholesterin (biliary sand) in the gall-bladder may
give rise to recurring paroxysms of pain, unaccompanied by any other
symptoms, which defy diagnosis.

Diagnosis of Biliary Colic. — It is distinguished from the two other forms
of colic in Table XIII., § 172. The severity of the pain and its paroxysmal

S 241 ] 0ALL-8T0NS3 353

character usually distinguish it from all other acute diseases of the liver.
Pseudo-biliary colic is sometimes met with in nervous women. The diag-
nosis from cancer of the liver may be very difficult. Both occur at the
same age, and both cause jaundice ; further, cancer may follow after
years of trouble from gall-stones. In cancer, the jaundice comes on and
steadily gets more and more intense. It must be remembered that in
some cases gall-stones are passed without colic, but with jaimdice ; conse-
quently, recufrring aUachs of jaimdice in an elderly woman should lead one
to suspect gall-stones. In all suspected cases the stools should be care-
fully examined for stones. The presence of ascites points to cancer, for
it rarely exists long without the effusion of fluid into the peritoneum.

The Symptoms of gall-stones at rest in the gall-bladder (cysto-
cholelithiasis) are often very obscure, and occurring as they do in
elderly females are very apt to be mistaken for cancer. (I) Enlargement
and tenderness of the gall-bladder can generally be made out below the
ninth costal cartilage, unless it is obscured by adhesions, or by Riedel's
lobe, a local hypertrophy of one lobe of the liver sometimes associated
with chronic cholelithiasis (see § 188). But, on the other hand, the enlarge-
ment of the gall-bladder may be mistaken for cancer, from which it can be
distinguished only by the long duration of the illness. (2) Attacks of
" biliary fever " — i.e., " chills,'* or shivering, with slight rises of tempera-
ture of a malarial type — at intervals for months or years are perhaps the
commonest complaint. (3) Local pain or discomfort is not always present,
but> like (1), it may from time to time be produced or aggravated by
exertion. (4) For the rest, the symptoms are negative — ^no jaundice,
ascites, or other symptoms — only a condition of general ill-health, due
to septic absorption from the ulcerating and irritated gall-bladder. (5) The
stones may on rare occasions become encysted, but far more often ulcera-
tion, perforation, abscess, and flstula result, unless the surgeon inter-
venes. Carcinoma of the gall-bladder is usually preceded by gall-stones.

Etiology, — (i.) Gall-stones are much commoner after than before fifty
years of age ; (ii.) are much more common in women than in men ; and
(iii.) in stout persons of sedentary habits, who consume a diet rich in fat
and sugar, (iv.) There is frequently a history (family or personal) of gout,
asthma, or migraine, and S6nac foimd 98 out of 128 cases were associated
with urinary gravel. They are less common in hot countries. When
gall-stones are already formed in the gall-bladder, an attack of biliary
colic is often determined by a sudden strain or an overloaded stomach.

Course and Prognosis, — The prognosis as to recovery from an attack of

biliary colic is excellent, but recurrence may be expected. A stone usually

forms in the gall-bladder and becomes impacted for a time in the neck of

the cystic duct, giving rise to biliary colic without jaimdice. It then

passes down the common duct, where it causes jaundice. This rarely lasts

more than a few weeks, but rare cases have been reported where it lasted

two years. Impaction for any length of time leads to consequences, which

may be classified thus : (i.) Ulceration of the ducts, vrith pyrexia, or

354 THE LIVER [§242

abscesses of the liver and bile-ducts, and consequent subacute pyaemia ;
(ii.) perforation into adjacent tissues, leading, for example, to fatal peri-
tonitis ; (iii.) inflammation and abscess of the gall-bladder, which may open
externally, perforate into the peritoneum, or ulcerate into the intestines ;
(iv.) formation of fistvla between the gall-bladder and the colon or duo-
denum, through which stones can pass of such a size that they may cause
intestinal obstruction.^ Cancer may supervene in later years.

Treatment. — (a) During the attack anodyne treatment is called for.
Opium or a hypodermic of morphia and atropine should be given (F. 25).
Chloroform inhalations are used in severe cases. Other drugs recom-
mended are chloral, spt. setheris, antipyrin, and ext. belladonnse, gr. i
every two hours. Of late years olive oil, in doses of at least 6 ounces, has
been strongly recommended as causing rapid passage of the stone into the
duodenum, but the author's experience does not support this. Hot water,
with 1 drachm of sodium bicarbonate to the pint, may be tried. If the
patient is put into a warm bath (100^ F.), and kept there till he shows
signs of weakness, an attack of pain may be warded o£E. Hot turpentine
stupes may give relief.

(b) Betipeen the attacks the habits of the patient must be corrected. Wine,
beer, and sugar must be avoided. A prolonged course of alkalies, and
sodiimi salicylate, or of such mineral waters a» Vichy and Carlsbad, is
advisable. Turpentine (n\^x.), in capsules, is said to aid the alkaline
treatment. The treatment for Congestion (§ 238) is applicable. Surgical
treatment is necessary whenever there is suppuration, when the gall-
bladder remains distended, when the common duct is blocked, or when
biliary colic frequently recurs.

f 242. Digeases ol the Oall-bladder are chiefly manifested by pain and enlargement
or swelling of the gall-bladder, which first appears just beneath the tip of the ninth
right costal cartilage. For the fallacy of Riedel's lobe see Abdominal Tumours, §§ 187,
188. Mayo Bobson gives the following classification of diseases of the Gall-bladder
and Bile-ducts :

A. Catarrhal Inflammationf : (a) Acute Catabbh (which corresponds to Catarrhal
Jaundice, § 239) ; {b) Chronic Catabkh. B. Suppurative Inflammationf : (a) StJP-
PUBATTVE Catarrh, which may consist of — (a) Simple empyema, and (/3) suppurative
cholangitis ; (6) Uloeratiok, Perforation, Fistula, and Stricture of the gaU-
bladder and bUe-ducts ; (c) Acute Phlegmonous Inflammation and gangrene of
the gall-bladder.

(Tronic Catarrh of the gall-bladder presents symptoms resembling those due to
gall-stones within it^ vide supra), but there is less pain, very slight jaundice, and no
tenderness on pressure over the region of the gall-bladder.

Simple Empyema of the gall-bladder, without involvement of the hepatic ducts,
is nearly always due to gall-stones. There is swelling, with continual localised pain
and tenderness ; and the abscess may burst in various directions, or point externally.

Suppurative Cholangitis is practically indistinguishable from pysdmic abscesses
(§244).

Ulceration of the gall-bladder is referred to above under Gall-stones (§ 241), and
Perforation is usually a result of the same lesion.

^ Large gall-stones may gradually ulcerate through from the gall-bladder to the
duodenum, in some oases almost without symptoms. Murchison coUeoted some
thirty-four of such cases where the gall-stone was large enough to give rise subsequently
to intestinal obstruction.

K 248, 244 ] PEMIHEPATITia^ABSCESS 366

SxaiCTirBB is generally also a consequence of the ulceration following gall-stones,
but it may sometimes be due to other lesions (see § 231 ). The result depends upon the
position of the stricture. In the cystic duct it leads to distension of the gall-bladder.
In the common duct it leads both to distension of the gall-bladder and considerable
enlargement of the liver. It is rare in the hepcUic duct, where it produces enlargement
of the liver.

Agutb Phleqmonous Inflammation of the gall-bladder (phlegmonous chole-
cystitis) is a rare affection (Courvoisier collected only seven cases). It comes on
suddenly, with symptoms resembling perforative peritonitis, and is difficult to
diagnose from acute appendicitis. It is usually rapidly fatal unless dealt with
surgically.

Membranous or Fibrous Cholecystitis, secondary to retained gall-stones, has
been recorded by Dr. H. D. RoUeston ; a cast of the gall-bladder is passed with hepatic
colic. The condition is diagnosed from gall-stone by finding the cast in the stools.

The less common Acute Disofden of the Liver remain to be considered,
viz., Perihepatitis, Abscess of the Liveb, and Acute Yellow
Atrophy.

lY. The jxUient complains ofFAinf and tenderness in the hepatic region,
aggravated by movement. There is no jaundice, and other hepatic symp-
toms are absent. The malady is probably Perihepatitis.

$ 248. Perihepatitif is inflammation of the capsule of the liver, which becomes
opaque and thickened, and by its contraction may lead to considerable distortion
of the shape of the liver.

Symptoms. — (i.) Acute attacks usually set in suddenly, with pain in the hepatic
region, radiating to the shoulder, and there is tenderness, increased on movement,
pressure, or cough, (ii.) Fever is absent as a rule, and the patient may appear to be
in his usual health, (iii.) Friction may be felt or heard, (iv.) Unless some other
disease is present, there is no jaundice. Recurrent attacks lead to thickening of the
capsule, recurring ascites, necessitating repeated tapping, and occasionally jaundice.
The puckered liver, with its thickened, rounded, distorted edge, can sometimes be
made out. The history of a Cause, especially syphilis, is usually obtainable. It is
sometimes part of an inflammation of the liver itself, or is associated with an abscess,
tumour, or cirrhosis. Sometimes the inflammation extends from adjacent organs, as
in pericarditis, pleurisy, or gastric ulcer, or it may be part of a general peritonitis.
Perihepatitis occasionally complicates acute or subacute rheumatism.

Diagnosis. — ^The characteristic pain and the absence of jaimdice differentiate it
from many other liver diseases. The conjunction of syphilis is also very helpful.
Cases of cysto-cholelithiasis (§241) or gumma of the liver may at times be mistaken
for perihepatitis.

Prognosis. — Simple cases tend to recover. In cases which have lasted for a long
time a certain amount of cirrhosis of the liver ensues. Portal obstruction may ulti-
mately result from puckering at the fissure, and considerable distortion of the liver
may result in the same way.

TreatmenL — ^The diet must be spare, and the patient must be kept warm. Salines
are given, with blue pill and rhubarb. Externally, hot fomentations and poultices
give relief, and if the pain is severe, leeches are recommended. The cause when known
must be treated — e.g., syphilis with iodide of potassium.

V. There is ENLAROEiiENT of the liver, accompanied by pain and tender-
ness, arhd the boundaries of the area of dulness are irregular ; there are
shiverinos, sweating, and intermittent pyrexia. The disease is
Abscess of the Liver.

§ 244. Abscess of the Liver. — Solitary or multiple collections of pus may occur in
the liver, due to septic infection, to suppuration of the bile channels, or portal vein,
or more rarely to suppuration of pre-existing morbid conditions, such as hydatids or

356 TBB LIVEB {{244

gummata. ** Tropical '*'* abscess occurs after dysentery, and is due to the amoeba
coll ; it is usually solitary, whilst pysemic abscesses are usually multiple.

Symptoms, — (i.) The onset is usually acvU, with pain and tenderness of the liver,
accompanied perhaps by a dry cough, with shallow respiration and digestive distur-
bance. The pain is affected by respiration, and is worst when the patient lies on the
left side, (ii.) The liver is enlarged, and the enlargement may extend downwards,
or more often upwards, even to the nipple. There may be fluctuation, (iii.) More or
less jaundice is present as a rule, (iv.) Constitutional symptoms are marked. There
is usually high fever, continuous at first, then with increasing oscillations. Rigors
and sweats are common. Later on the patient falls into the typhoid state, with emacia-
tion, vomiting, diarrhoea, and delirium.

Besides the acute type just described, there is an ctsihenic variety, with insidious
onset, general failure of the health, and periods of continuous or intermitting fever,
followed by intervals of apyrexia, resembling malaria. Cough and dull aching over the
liver and in the right shoulder are generally present from the beginning. The tropical
abscess occasionally has no symptoms.

Diagnosis. — (i.) The pain and pyrexia disting^uish abscess from hydcUid (when not
in a suppurating condition), (ii.) A distended and inflamed gaU-Uadder is recognised
by a history of gall-stones, and its outline may be palpable on examination, (iii.) Ab-
scess is often mistaken for severe ague. But ague is amenable to quinine, the eleva-
tions of temperature are periodic, and each x)aroxysm has three stages, (iv.) A hepatic
abscess may be diagnosed from other swellings of the liver by exploratory aspiration,
giving the reddish " anchovy sauce " coloured pus, which is distinctive, (v.) A low
form of pneumonia at the base of the right lung so frequently accompanies liver abscess
that its presence is an important aid to diagnosis in obscure cases.

The insidious cases of liver abscess are always difficult to diagnose, and where
health is deteriorating, with obscure pyrexial conditions from time to time, almost
every general or local inflammatory disorder may be suspected before liver abscess.
Manson advises the physician in tiie tropics to suspect liver abscess in all obscure
abdominal cases with evening rise of temperature. On the other hand, cases have
occurred where medical men, diagnosing abscess, have explored the enlarged livers of
leucocythcemia and pernicious ancsmia. This mistake may be avoided by examining
the blood before resorting to puncture.

Etiology. — Hepatic abscess, single or multiple, may arise from — (i.) Suppuration in
a pre-existing focus of disease — e.^., hydatid, gumma, tuberculous abscess, actino-
mycosis, or malignant growth ; (ii.) ulceration of the biliary passages such as occurs
in cholecystitis ; (iii.) ulceration of the alimentary canaL In this case the absoeeses
are usually multiple, except in amoebic dysentery : in this condition there is a large
abscess, the contents of which are sterile except for the presence of the amoeba. Such
an abscess may become secondarily infected with staphylococci, etc. (iv.) Inflamma-
tion and pus-formation in the abdomen, especially in cases of old-standing suppuration
of the pelvic organs and in appendicitis, (v.) Occasionally operations on the rectum
or in any septic area produce an abscess in the liver, consequent on the conveyance
of a septic embolus by the portal vein, (vi.) Pyaemia, (vii.) Trauma is credited with
the causation of abscesses in a few cases.

Prognosis. — (1) The case mortality varies from 57 to 80 per cent. Death usually
takes place in three weeks in cases with multiple abscesses. The pyreida increases,
and the patient dies in the typhoid state. (2) Solitary abscess may lead to death in a
month, or the patient may live for one to two years, with obscure symptoms as
described above, (i.) The abscess may burst into the peritoneum, pericardium, or
alimentary canal, with a fatal issue, or it may open externally and gradually recover
by free discharge, (ii.) Frequently the abscess, especially a ** tropical '* abscess,
bursts into the right lung or the pleura. The patient develops a severe cough, with
signs of consolidation of the right pulmonary base, and the abscess contents are
brought up as a red-coloured sputum. Recovery may result, or the continued dis-
charge may lead to death from exhaustion or lardaceous disease.

TreaimenL — ^When the evidence points simply to acute inflammation of the liver,
before the temperature leads one to suspect pus formation, anodyne treatment, such
as cupping and hot poultices are employed. Ammon. chlor. (20 grains t.i.d.) oj

H 246-247] SUBPHRENIC ABSCESS 357

ipeoaouAoha (if amoebio dysentery bo present) are the best drugs. Saline purga-
tives, spare diet, and absolute rest in bed are necessary. As soon as an abscess is
suspected, exploratory puncture must be performed ; at least six punctures should be
made before abandoning the attempt to find pus. If an abscess is discovered, free
drainage must be established. Sir Patrick Manson advises the use of a large trocar,
through which a drainage-tube is inserted. Leonard Rogers has replaced drainage
by flushing out, two or three times daily, with a solution of quinine.

§ 245. Sabphronio Abicesf (Abscess beoieath the Diaphragm). — The Symptoms are
much the same as those of tropical liver abscess. When occurring above the right
lobe, the liver dulness is continued up in the axilla, perhaps as far as the level of the
nipple, and is convex, or dome-shaped, upwards. The base of the right lung shows
signs of congestion, and there are evidences of pleurisy at one or both bases. ^

Etiology, — In men the most common causes are appendicitis and ruptured duodenal
ulcer ; in women gastric ulcer. Other causes are extension of hepatic abscess, empyema
perforating the diaphragm, extension of kidney or pelvic abscess, and local tuber-
culous or (rarely) cancerous processes.

Diagnosis, — In a case of suspected abscess exploratory puncture may be performed.
The needle should not penetrate beyond 3^ inches, so as to avoid puncturing the
portal vein. In a right-sided empyema of the chest the upper border of the dulness.
when continuous with that of the liver, is concave, being higher towards the spine.
In hepcUic abscess the liver is tender and enlarged below the costal margin, but it is
often impossible to distinguish subphrenic from hepatic abscess. A variety containing
air so greatly resembles pneumothorax that it is called pyopneumothorax subphrenictLs.
Exploratory needling, sometimes under chloroform, should be employed to complete
the diagnosis. It is usually due to perforated gastric ulcer or abscess of the lung.

The Prognosis is fair if surgical treatment is carried out thoroughly and in time.

§ 246. Aotinomyooiii of the LiTer is a condition which may be mistaken for abscess
of the liver. It is due to the absorption of the ray fungus from the intestines, and
starts as one or more foci in the liver substance, which slowly enlarge into spherical
masses, and which may undergo suppuration, though the frequency of this latter is
debated.

The Symptoms consist of vague uneasiness referable to the liver, with gradually
increasing enlargement — at first uniform, later on unequal, the organ becoming
prominent in one place. Exploration with trocar may yield no results ; but if the
tumour is laid open, the characteristic greenish fluid with yellow specks is obtained
in which the ray fungus is found, which clinches the diagnosis.

VI. The illness has been ushered in by deep jaundice and profound constitu-
tional SYMPTOMS ; the liver dulness diminishes rapidly. The disorder is Acute
YitiiLOw Atrophy of the Liver.

§ 247. Aoate Tellow Atrophy (Malignant Jaundice, Icterus Gravis^) is a disease
characterised by intense jaundice and cerebral symptoms, extensive necrosis of the
liver cells, with rapid diminution in volume of the organ, occurring especially in
pregnant women, and usually ending fatally.

Symptoms. — (i.) The premonitory symptoms may be slight, resembling a catarrhal
jaundice. There is increasing tenderness over the liver, (ii.) In a few days or weeks
severe symptoms set in, with deepened jaundice, headache, and delirium, and the
patient passes into the typhoid state, (iii.) HsBmorrhages occur from the stomach,
bowel, and bladder, and there may be petechias imder the skin, (iv.) Fever is usually
absent during the course of the illness, but at the end it may be high, (v.) With the
onset of the severe symptoms the liver dulness begins to rapidly diminish. The
spleen is usually enlarged, (vi.) The urine is characteristically altered, having a
marked diminution in uric acid, urea, and salts, while leucin and tyrosin are found
crystallising out on evaporating a few drops of urine on a slide (Fig. 72).

^ Mr. H. L. Barnard has described six clinical varieties, according to the position of
the abscess {BriL Med, Journ,, 1908, vol. i., pp. 206, 371, 429).

2 " Icterus gravis " is a term used sometimes in a generic sense for any very severe
jaundice tending to a fatal issue. Acutc^yellow atrophy is, according to modem
researches, only one form of it.

358 THE LIVER [§248

Diagnosis. — Acute Yellow Atrophy is not likely to be mistaken for any other liver
disease after the acute symptoms set in. Phosphorus poisoning may closely resemble
it, but in that condition the liver is enlarged, and signs of irritant poisoning precede
the onset of the jaundice.

Etiology. — Predisposing Causes. — (i.) Acute Yellow Atrophy is most common under
middle age, though rare in children ; and (ii.) in women, especially during pregnancy,
(iii. ) Dissipation and excesses of any kind are said to predispose. Exciting Causes. — It
is said that the onset of this disease has often been preceded by severe mental emotion ;
and malaria, influenza, and other blood poisons have been said to determine its onset.
The malady is probably microbic in origin.^

Prognosis. — ^The disease is very fatal. After the severe symptoms set in the patient
usually dies in a comatose condition within a week. Pregnant women usually abort.

The TreatmerU is very unsatisfactory. During the preliminary stage the disease
is treated as in catarrhal jaundice. Warm baths, diaphoretics, and diuretics may be
tried.

CHRONIC DISEASES OF THE LIVER,

§ 248. Routine Procedure. — It will be remembered (§ 237) in the physical
examination of a patient suspected to be suffering from hepatic disease that
the iirst and most important question to investigate is whether there is any
aUeration in sizBy especially enlargement of the organ (by palpation and
percussion). (2) For reasons which will be apparent below, the question
next in order of importance is whether theie is any pain or tenderness in
the organ. And then (3) is there any jaundice ? (4) Is there any ascites ?
(5) In every case of suspected liver disease the spleen (§ 258) and the urine
should be carefully examined.

The wxai^TOViS fallacies in the alteration of the size of the liver dulness
must be carefully studied (§ 235).

dassiflcatioiL — By common consent chronic diseases of the liver are
divided into those in which the area of dulness is not increased, and
those in which the area of dulness is increased ; and these latter are
grouped into painful and painless enlargements.

A. The organ is of nonnal or diminished size in —

I. Functional derangement of the liver . . . . • • § ^9

II. Atrophic (alcoholic) cirrhosis . . . . . . • • § 250

B. The organ is increased in size, —

a. Without pain or tenderness —

I. Hypertrophic cirrhosis (alcoholic and other) . . • • § 251

II. Fatty liver . . . . . . . . . . § 252

III. Lardaceous liver . . . . . . . . • • § 253

IV. Hydatid and other rare conditions . . . . • > § 254

6. With fain or tenderness —

I. Chronic congestion . . . . . . . . • • § 255

TI. Cancer of the liver . . . . . . . . • • § 256

III. Abscess of the liver . . . . . . . . . • S 244

A. In the first group, in which the liver is of nonnal or diminished size,
there are only two disorders, I. Functional Derangements ; and
II. Alcoholic Cirrhosis ; and these are two of the commonest hepatic
disorders met with.

^ See Koport of the Path. Soc. London, the Lancet, November 4, 1900.

§249]

FUNCTIONAL DERANGEMENT OF THE LIVER

369

Table XIX. — Chronic Diseases of the Liver.

Slse and Surface.

Pain. Jaundice. Ascites.

I. Adyakobd Cirrhosis ov
THB LiTSR {atrophie
alcoholic cirrhotit).

la, HTPERTROpmo Cir-
rhosis. Of alcoh(dio,
syphilitic, or biliary
origin.

n. Chronic Conqbstion.

m. Fatty Liysr.

After enUrgement it be-
comes DIMIiaSHSD.

Surface irregular (hob-
naU).

Enlargement may be
very great. Surface
hard and may be
nodular.

Slight enlargement. Sur-
face smooth.

None.

Generally A yery
, absent, prominent
I never , sjrmptom.

marked.

Varies.

Usually
absent.

Moderate enlargement.
Sorfaoe smooth.

rv. Lardaoboits or Amyloid

LiVKR.

Enlargement may be
very great. Surface
smooth.

Present, Slight,
but slight, i

Usually
some.

Absent. Absent. Absent.

Absent. Absent. | Absent.

I V. Cancer of Liver.

VI. HYDATID Liver (rare in
this country).

Great enlargement. Sur-
face uneven.

Outline of dulness arched
or distorted.

Severe.

i Absent
I unless near
I surface.

Usually
present.

Usually
absent.

Usually
present.^

Absent.

1. There is no alteration in the size o! the liver, but the patient complains
of LETHARGY, vogue digestive disturbances, sleepiness after mealsy Jurred
indented tongue, constipation, headaches, and there is a frequent deposit of
LiTHATES IN THE URINE on cooling. There is probably Functional De-
rangement OF THE LrVER.

§ 249. Functional Derangement of the liver ^ certainly constitutes one
of the commonest of the minor ailments that affect a highly civilised com-
mimity. Very careful percussion may perhaps detect slight enlargement,
but generally, if there is any enlargement present, it indicates congestion.
Active (§ 238), or Passive (§ 255).

Symptoms. — There are two manifestations of functional derangement
which deserve special notice — constipation and lithuria. 1. The common
complaint, " My liver is sluggish," is often equivalent to saying that the
bowels do not act properly. Certainly, constipation, attended by pale-
coloured faeces, due to a deficiency in the amount of contained bile, is
a frequent accompaniment of disordered liver. The amount of bile in
the stools is not, however, an absolute guide to the activity of the liver.
DiarrhcBa alternating with constipation, and flatus passed per rectum,
may be present.

2. Lithuria — i.e., excess of urates in the urine, which appear when the
urine cools as a pink or orange deposit — is evidence, according to Mur-

^ The pieaenoe of jaundice and ascites depends on enlargement of the glands in the
fissure, generally considerable in the later stages.

^ The introdnotoiy remarks at the head of this chapter may well be pemsed in this
connection.

360 THE LIVER [§840

cUson and many of his followers, of defect in the liver function, more
especially of that function which is concerned in the disintegration of
nitrogenous foodstuffs. Such deposits are met with when the quantity
of urinary water is markedly deficient, or when the proportion of proteid
in the diet is in excess ; but excluding these causes, there are three patho-
logical conditions with which lithuria is specially associated — (a) FebrUe
diseases — e.g., ordinary febrile "catarrh" — where the liver cells may
become granular, and the whole organ may be enlarged and congested ;
(6) structural diseases of the liver, especially such as are attended by con-
gestion ; and (c) functioned derangement of the liver (Murchison). Under
these circumstances, which more particularly concern us now, the deposit
of lithates in the urine is a " manifestation of a morbid condition of the
blood and of the entire system," for which Murchison suggested the term
lithaemia. It is due to the presence in the blood, not necessarily of lithic
acid, but of numerous partially elaborated products belonging to the
chemical series which connects proteid food on the one hand with uric
acid, and urea on the other. It is accompanied, according to the same
authority, by a great variety of symptoms — depression of spirits, irrita-
bility, lethargy, a disinclination for work, aching pains in the limbs,
headache, vertigo, sleeplessness sometimes, undue drowsiness at others,
dyspepsia, palpitation, irregidarity of the pulse, and high tension, or
sometimes enfeeblement of the circulation and general enfeeblement of
the body.

3. " Functional derangement of the liver may exist for years without
any other symptom than the frequent deposit of lithates, and occasionally
lithic acid, in the urine. But if neglected it may ultimately be the means
of developing gout, structural diseases of the liver and kidneys, or some
other serious malady " (Murchison).

4. Sugar in the Urine — i.e., temporary or permanent glycosuria (dia-
betes), may in many cases, if not in all, be regarded as a manifestation of
functional derangement of the liver ; but we are still in the dark concerning
the pathology of this symptom.

It may, however, be assumed that glycosuria might arise in one or more of three
ways : (a) Imperfect glycogenosis in the liver, the sugar passing through the liver un-
changed ; (b) increased conversion of glycogen into sugar, which results whenever the
circulation through the liver is increased — e.g.f by vaso-motor paralysis of the hepatic
artery ; and (c) diminished destruction of sugar in the blood or tissues.

Etiology of lAthoemia. — Functional disorder of the liver (and conse-
quently lithsBmia and the other symptoms above named) may be secondary
to (a) the continual over-functioning of the organ, (6) to diseases of the
alimentary tract, (c) to diseases of the heart or lungs, and (d), as above
mentioned, to pyrexia. "When primary, its principal causes are — (1)
Errors of diet, especially rich, sweet, greasy foods, and alcoholic beverages.
Alcohol cornbin^ with sugar {e.g., port and other fruity wines) is specially
injurious; or taken in the form of undiluted spirit, particularly on an
empty stomach, is infinitely more harmful than dilute alcohol at meal'
times. (2) Deficient swpjUy of oxygen, such as deficient exercise, or con-

§849] FUNCTIONAL DERANGEMENT OF THE UVER 361

fmement in ill-ventilated rooms. (3) Tropical dimates, especially when
combined with indulgence in unsuitable food or alcoholic excess. (4) '* Pro-
longed menUd anxiety, worry, and incessant mental exertion " (Murchison).
(5) Certain constitfitional peculiarities, for the most part inherited, may
render one person much more susceptible than another to any of the above
causes.

Treatment of Lithcemia, — (1) Diet is certainly the most important
feature of the treatment. Avoid particularly sugars, fats, and alcohol.
All highly seasoned and rich foods, sweets, pastry, butter, and, in severe
cases, potatoes and fruits may have to be given up. ** In most cases of
lithaBmia, a diet consisting chiefly of stale bread, plainly-cooked mutton,
white fish, poultry, game, eggs, a moderate amoimt of vegetables, and
weak tea, cocoa, or coffee answers best ; while in others the patient enjoys
best health on a diet composed of milk, farinacea, vegetables, eggs, and
occasionally fish." ^ Haig's diet for uric-acid«emia, as he terms lithsemia,
is still more rigorous,* and undoubtedly the quantity as well as the quality
of the food must be regulated. There is no doubt that many sufferers
from lithsamia take more food than can be dealt with by the liver. It is
here that inherited peculiarities play such an important part, for what is
too little food for one man may be too much for another. Various dietaries
are given in § 212. (2) Abundant exercise in the open air to supply the
necessary oxygen is only second in importance to diet. (3) Hydragogue
and cholagogue aperients — e.g., the regular administration of salines
(Himyadi, Carlsbad, or Friedrichshall waters) every morning, and calomel
once or twice a week (P. 46, 51, and 67).^ (4) Personally I have found
bark or mineral acids (especially nitrohydrochloric) and bark, taken
shortly before meals, very efficacious in some cases. (5) Among the other
drugs, chlorides, iodides, and bromides are recommended by Murchison
for the various conditions, as indicated by the symptoms. Opium is
contra-indicated. If this treatment fails, turn to that of Acute Congestion
(§ 238).

^ Murchison, loc, cit., p. 615.

^ Dr. Alexander Haig's diet for uric-acidsemia consists of : Bread, 10 ounces ; oat-
meal, 2 ounces ; milk, 2 pints ; cheese. 2 ounces ; rice, 2 ounces, vegetables and fruit,
12 ounces. Vegetables, fruit, and bread may exceed these quantities, but this observer
maintains that the nearer a patient adheres to this dietary, the loss likely is he to
su£fer from uric-acidaemia. gout, rheumatism, and allied diseases. These diseases he
regards as being lareely dependent on faulty diet, and especially the consumption of
animal food (proteios) in excess, and such as contain uric acid and its antecedents
(e.g., xanthin). The foods quite free from these substances are bread, macaroni, rice,
and other cereals, potatoes, vegetables, nuts, and fruit.

^ Luff foimd that the gelatinous Sod. biurate is precipitated in crystalline form on
making alkaline a blood serum with sod. bicarb. But if Pot. bicarb, is added, this
action is delayed, and the precipitate less in quantity. Thus is explained the advantage
of Pot. salts in acute and subacute gout, and the use of vegetables which are rich in
Pot. salts. In gouty people the blood is not less, but really more alkaline than normal,
from excess of soda salts, which hasten the crystalline deposit. ** Causation and
Treatment of Gout," Lancet, November 18, 1899, p. 1361, and Brit. Med. Joum., 1899,
vol. ii., p. 1163. See also Discussion, Brit. Med. Asso., Lancet, vol. ii., 1899, p. 441,
and " Uric Acid," by Haig.

362 THE LIVER [ § 260

II. The area of liver dulness is diminislied, and if the surface can befell
it is HARD AND UNEVEN (hobnail) ; ascites is probably present, but no very
distinct jaundice ; ike spleen is enlarged^ <md the patient is subject to bjbmor-
BHOiDS, and hemorrhages from the stomach and bowd. The disease is
Atrophic Alcoholic Cirrhosis.

§ 250. Atrophic (Sirhosis of fhe liver, or, as it is sometimes callecU
Alcoholic Cirrhosis, Interstitial Fibrosis of the Liver, or Interstitial
Hepatitis, consists of a progressive degeneration of the liver cells, with an
increase of the interstitial fibrous tissue, leading to portal obstruction,
and a shrinkage of the organ. Pathologists are now agreed that the
interstitial fibrosis is secondary to the atrophic degeneration of the hepatic
cells. Fibrosis or cirrhosis of the liver must still be regarded as mainly
the result of alcoholic excesses, especially the habit of dram-drinking on
an empty stomach. Clinically there are two varieties of Alcoholic Cirrhosis
— ^the Atrophic form, which is a very common condition ; and the Hyper-
trophic form, which is relatively rare. The adjectives have reference to
the size of the organ, for whereas the Atrophic form soon becomes diminished,
the Hypertrophic form is enlarged throughout the disease. The hyper-
trophic form is further distinguished by a tendency to jaundice without
ascites ; and histologically the fibrosis has a uni-lobular distribution,
instead of being multi-lobular as in atrophic cirrhosis.

Symptoms. — (1) In the early stage of the disease the organ may be
enlarged, though rarely much so ; but in the second and third stages the
liver dulness is diminished. The liver is small and hard, and the surface
is often nodulated, hence it is known as the " hobnail," or " gin-drinkers' "
liver. There is a feeling of imeasiness and weight in the hepatic region.
(2) The onset of the disease is very slow and insidious, extending some-
times over years. Gastric symptoms, such as morning sickness, and the
other symptoms of alcoholic dyspepsia, are alone complained of for a
considerable time. These are followed by symptoms of chronic gastritis,
debility, and emaciation. The patient's aspect is very characteristic,
with dilated venous stigmata in the cheeks. (3) Jaundice appears in the
later stages of the malady in about one out of three cases. (4) Symptoms
of portal obstruction occur (§ 236), and haematemesis is sometimes the
first obvious symptom ; the spleen becomes enlarged, and ascites (which
is present in 80 per cent, of the cases) may be very considerable in amount.
(5) In the concluding stages of this disease, when the secreting tissue of the
liver is destroyed, the patient falls into a comatose state, with muttering
delirium, which resembles uraemia and the typhoid state, except that there
is pyrexia in the latter. This precise clinical resemblance is quite in
keeping with the fact that the liver takes part in the elaboration of urea ;
so that when its cells are destroyed the blood becomes charged with a
number of nitrogenous products, which cannot be eliminated.

Etiology, — (1) Cirrhosis of the liver is most common between thirty-
five and sixty; it is rare under twenty-five. Men are much more fre-
quently affected than women. (2) Alcohol is undoubtedly the most usual

§ 250 ] ATROPHIC CIRRHOSIS OF THE LIVER 363

cause of atrophic cirrhosis, especially when taken in small quantities,
frequently, or when taken neat on an empty stomach, the patient perhaps
never becoming intoxicated. (3) In cases where no alcoholic history is
obtainable it is believed that bacterial toxins are in operation.

Diagnosis, — Cancer of the liver is only difficult to diagnose from cirrhosis
in the early stages ; but usually it runs a more rapid course, and is accom-
panied by more pain, and more intense jaimdice. The spleen is not
usually enlarged in cancer. In jxissive congestion of the liver with ascites
there are evidences of a cause, such as heart or lung disease. In the
absence of ascites early cirrhosis may be mistaken for the other causes of
liver enlargement. Chronic peritonitis with efEusion may not be recog-
nised as such imtil the organs can be palpated after paracentesis.

Prognosis, — The disease has a slower and more insidious onset than
hypertrophic cirrhosis (below), and is in most cases a more serious con-
dition. If the patient is seen before signs of portal obstruction supervene
much can be done, but if not imtil afterwards, the prognosis is grave.
The outlook is more favourable in patients who are young (under thirty),
and where the general health is good. TJfUoward Symptoms. — ^Although
restoration to comparative health has occurred after the development of
ascites, it remains true that, as a general rule, with the onset of rapid
ascites the end is in view, the patient rarely living more than a few months.
When there is rapid reaccumulation of fluid after paracentesis, and little
benefit is derived from treatment, the course tends towards an early
death. Pleurisy, renal disease, or peritonitis are occasional complications.

Treatment in the early stages is practically the same as that employed
for chronic congestion of the liver, and chronic gastritis (§§ 255 and 209).
The habits of the patient must be corrected, and the diet reduced to the
simplest elements ; milk should be the staple diet in advanced cases.
Alcohol must be completely cut off, and regular exercise taken. A course
of salines should be ordered to be taken in the early morning, and rhubarb
or mercurial pills at night. Ammonium chloride and iodide of potassium
are valuable remedies in the stage of enlargement of the liver. If portal
obstruction and ascites have set in, see § 185. Patients sometimes recover
after repeated tappings, which gives time for the establishment of the
collateral circulation ; and recently surgical measures have been adopted
for the artificial production of peritoneal adhesions for the establishment
of the collateral circulation. The one usually adopted is " epiplopexy "
or stitching the omentum to the anterior abdominal wall.

We now turn to those chronic liver diseases in which the area of dulness
is increased. These may be divided into two groups — ^those without
PAIN AND TENDERNESS, are described immediately below. If the enlarge-
ment is attended with pain and tenderness, turn to § 255.

There are four diseases with enlargement of the liver without pain and
tenderness : 1. Hypertrophic Cirrhosis ; II. Fatty Liver ; III. Larda-
OBOUs Liver ; and IV. Hydatid and other rare diseases. In Catarrhal

364 THE LIVER [ § 851

Jaundice (§ 239), Chronic Cholelithiasis, and some other disorders,
the liver is somewhat enlarged, but this is not their main feature

I. The liver is enlarged and painless ; its surface is hard, jaundice
IS PRESENT, but little or no ascites, and there is a long history of failing
health. The disease is probably Hypertrophic Cirrhosis.

§ S51. Hypertrophic Cirrliosis of the liver is a term employed in a
generic or clinical sense to indicate a progressive enlargement of the liver
due to an increase in the connective tissue of the organ with a tendency
to jaundice. The condition may occur under at least Ave different aspects,
due respectively to Alcoholism, Syphilis, Gall-stones, Chronic Heart-disease,
and Malaria. It may also be associated with Splenic Anaemia (then
called Banti's disease). A rare variety of hypertrophic cirrhosis accom-
panied by pigmentation of the skin has been described under the
name of hsemochromatosis. Sometimes this is attended by glycosuria,
and has been called *' bronzed dlabetes." The pigmentation resembles
that of Addison's disease, but the liver is larger than in that disease.
The pigment contains iron.

la. Hypertrophic Biuary Cirrhosis (synonym : Hanot's disease). —
In this form of cirrhosis the fibrous overgrowth occurs around single
lobules, hence the name '' uni-lobular cirrhosis." The disease is now
classed by some authors as a distinct form of alcoholic liver, in which the
organ is enlarged throughout the whole course of the disease ; and there is a
great tendency to jaundice, and but little ascites — features which contrast
with those of the more common condition. Atrophic Alcoholic Cirrhosis,
just described.

Symptoms, — (1) The symptoms come on very insidiously, with a failure
of the general health. The patient rarely applies for medical aid until
(2) jaundice has set in, which may be very pronoimced. The urine con-
tains bile, but the stools retain their normal colour. (3) Fever occurs at
intervals, and may be as high as 103° F. (4) In spite of the intense
jaundice there are few or no signs of portal obstruction, and ascites is
rarely, if ever, present. (5) The liver is uniformly, and may be consider-
ably enlarged, hard, and sometimes rough. There is no tenderness and
no.actual pain (except during the feverish attacks), though a dull weight
may be complained of in the hepatic region. The spleen is usually
enlarged. (6) A history of alcoholism is often present, but in most cases
the cause is obscure.

Diagnosis, — From atrophic alcoholic cirrhosis it is known by the absence
of signs of portal obstruction, § 250. Fatty and amyloid livers are not
accompanied by jaundice. Cancer has a more rapid and painful course.
And see Table XIX., p. 359.

Prognosis. — Sometimes patients die within twelve months, with an
acute onset of the typhoid state, but most live for a number of years,
with signs of progressive emaciation.

The Treatment of Congestion (§ 238) is applicable, according to the
predominating symptoms. Calomel, gr. ^\y to J t.i.d. for three days,

§252] HYPERTROPHIC CIRRHOSIS OF THE LIVER SeS

with intervals of three days, continued for months has good results ; and
drainage of the gall-bladder has cured some cases.

16. Cardiac Valvular Disease results, as we have seen, in very con-
siderable congestion of the liver. Long-continued passive engorgement
of the liver gives rise to changes known as the " nutmeg liver," accom-
panied by more or less enlargement of the organ ; and this may be attended
by a considerable degree of fibrosis. The diagnosis depends on the
presence of cardiac valvular disease and other features (see Passive Con-
gestion, § 255).

Ic. SYPHn.TTio DiSBASB of the liver generally takes the form of a diffuse hyper*
trophic fibrosis; or it may be met with in the form of gummaia. Undoubtedly,
hepatic fibrosis may result from both hereditary and acquired^ B3rphiiis, though
probably the gummatous form is commoner in the latter. In the inherited variety
two forms of fibrosis occur. In one there is fine diffuse fibrosis between the individual
cells (uniovular fibrosis) producing a imiformly smooth, firm liver ; in the other, coarse
fibrosis, with perihepatitis and much distension, occurs, as in the acquired disease.

The Symptoms are variable. The liver is moderately enlarged ; there is not much
tendency to jaundice and portal obstruction excepting ia the final stages. There may
be actual pain, especially when the capsule of the liver is involved ; but as a rule there
are only indefinite sensations of illness, accompanied in the gummatous cases by a
slight degree of intermittent pyrexia. In the gummatous form nodular projections
may possibly be made out on the surface of the organ. The presence of such pro-
jections, accompanied by intermitting fever and a history of syphilis, in a young adult
practically make the diagnosis certain.^ In the absence of a syphilitic history the
occurrence of pain and local tenderness at intervals points to syphilitic rather than
to alcoholic cirrhosis, because perihepatitis and the involvement of the capsule are promi-
nent features of syphilitic cirrhosis.^ In the diagnosis from cancer we have mainly
to rely on the efficacy of iodide, and the (usual) absence of jaundice and ascites in
syphilitic disease. If ascites be present the Wasserman reaction is more marked
with the ascitic fluid than with the blood.

The Prognosis, as a rule, is good, if the nature of the disease be discovered and it is
treated by large enough doses of potassium iodide and mercury.

Id, CiRBHOSis OF BiLiABY OBSTRUCTION. — Hypertrophic cirrhosis has been pro-
duced experimentcklly in one half of the liver by ligature of one hepatic duct, and it is
met with clinically in association with gall-stones, tumours or glands pressing on the
bile-ducts. When acting as clinical clerk to the late Dr. Charles Murchinson, I had
the opportunity of observing a case of this kind occurring in a woman, aged forty-five,
with a history of repeated attacks of biliary colic. There was great enlargement
of the liver, with jaundice of three years* duration. The acholic stools aid the diag-
nosis of this form of hypertrophic cirrhosis.

le. Malarial CiRBHOSis.---Subjects of prolonged malarial poisoning have an
enlarged liver, which is believed to be due to cirrhosis. Alcohol may possibly be a
contributory cause in these cases.

II. The enlargement of the liver is painless and uniform ; the surface
is smooth ar^ soft ; there is no jaundice or ascites, and the spleen is
NOT enlakqed ; there is a history of alcoholism, or the patient is suffering
from phthisis. The disease is probably Fatty Liver.

§ S52. Fatty liver is a condition in which fat is deposited in the hepatic

* I have met with several cases of marked diffuse fibrosis of the liver, due to ac-
quired syphilis. GIisson*s capsule was extremely thick, and large ramifying bands
passed from it into the organ in all directions.

^ A case of this kind is recorded by Bristowe in the Clin. Soc. Trans., vol. xix., p. 249.

' Cheadle, Lumleian Lectures, Brit. Med, Joum,, 1900, vol. i., p. 756.

366 THE LIVER [ §§ 25S, 254

cells, commencing in the periphery of the lobules. It is nearly always
associated with some other disease.

Symptoms. — (1) The liver is enlarged imiformly and is quite smooth.
(2) Pain, jaundice, and portal obstruction are absent. (3) The accom-
panying symptoms are due to the cause of the fatty liver, and may consist,
therefore, of debility, anaemia, etc. (4) The history oi a Cause is important
— viz., (i.) Chronic wasting disease, such as phthisis, (ii.) Fatty liver
appears in association with fatty heart (g.t;.) and general obesity, (iii.) It
often occurs consequent on chronic alcoholism ; and a mixed degeneration
of fat and fibrosis is not imcommon.

The Diagnosis from the painful enlargements of the liver is not diffi-
cult (see Table XIX.). From lardaceous liver it is known by the absence
of signs of lardaceous spleen or kidney, and by the absence of its cause.

The Prognosis and Treatment depend upon the primary disease — i.e.,
the cause. It is hardly likely th^t the fat can be removed.

ni. The enlargement o! the liver is uniform a/nd painless ; the surface
is smooth and hard ; there is no jaundice, no ascites ; the spleen is
ENLARGED ; there is a history of frdonged punderU discharge or constitu-
tional syphilis. The disease is Lardaceous Degeneration.

§ 258. Lardaoeous (Amyloid or Waxy) Liver is a oondition in which the liver tissue
is replaced by lardaceous material, which starts m the capillaries and smaller arteries
of the organ, leading sometimes to an immense enlargement.

Symptoms. — (1) The liver is enlarged imiformly and smoothly, and feeb firm and
resisting ; (2) pain, jaundice, and portal obstruction are absent ; (3) the constitutional
symptoms are due to the presence of the causal condition, and to the presence of
amyloid disease of other organs.

Etiology, — (i.) Long suppuration and purulent discharge, as from necrosed bone ;
(ii.) constitutional syphilis ; and (iii.) tuberculous disease of the lungs or elsewhere.
Amyloid liver has become much rarer since chronic suppurations have been obviated
by improved surgical methods.

Diagnosis, — ^The presence or history of a cause renders the diagnosis of amyloid
disease comparatively easy (see also Table XIX.).

The Prognosis depends upon the amount of amyloid disease elsewhere. Dianhosa,
indicating amyloid changes in the intestines, abundant pale urme. with albuminuria,
indicating amyloid disease of the kidneys, arc untoward signs. If the cause is remedi-
able, as by surgical treatment, the liver may decrease in size.

Treatment — ^The indications are (i.) to remove the cause, and (ii.) to keep up the
strength. The former is attained by administering potassium iodide in the case of
syphilis, and by surgical treatment in the case of long-standing discharges. Tonics»
such as iron and quinine with cod-liver oil are useful.

IV. The enlargement ol the liver is TAmhsss, btU kot uniform, and the upper
mc^gin of the liver dvlness is perhaps abchbd ; there is no jaundice or ascites and the spleen
is not enlarged ; a thrill or vibration is felt on percussion. The disease is Hydatid Cyst.

i 254. Hydatid Tumour of the Liver depends on the presence in the liver of a para-
site, rare in this country, though common in Australia, India, the Argentine, and
Iceland, where dogs live in close association with man, and in Russia, where wolves
are common.

Symptoms. — (i.) There is a slowly increasing enlargement of the liver, which is
smooth, globular, and elastic, sometimes fluctuating. The right chest may be bulged
outwards, with dulness in the axilla. When the fingers of the left hand are laid on
the tumour and tapped with those of the right hand, the " hydatid fremitus,** or
** thrill/* is felt in some cases, (ii.) Pain is absent unless the tumour is very near

i2M] LARDACEOUS LIVES— HYDATID 367

the Burfoce, when great pain nmy be prcBent, becaoae On eapmiie is mvolved. (iii.) No
ooaatitutional Bymptoms appear unlosB the tnmoar presses upon the aunonnding
structures, or becomes inflamed and suppurates, (iv.) Any part of the body may be
invaded, and the symptoms vary acooidingly. The praeenoe of multiple oysta in the
abdomen gires liae to a very characteriatio aenaation on palpation ; it is compared to
the sensation of palpating a bag of cricket balls. Jaundice may occasiooally be
caused by oysts lodging in the bile-ducts.

Etidogy. — 'The parasite ont«rs the alimentary oanal of man by means of drinking
water contaminated by fseces containing the ova of the tnnia echinococcus, a tape-
worm which may infect the dog. The embryo is carried to the liver, where it enoy^
and grows. The oyat so developed has a gelatinous wall, and contains a olear fluid ;
and from the wall a number of proscolices or embryonic beads develop, each with a
crown of most cbaActoristia booklets.

Diagnoait. — Abtcet at the liver produces pain and fever, and on aspiiation yields
grumouB material like anchovy sauce. Pleuritic tfftuion on the right side, leading to
dolnesa in the azilia, may resemble hydatid. In such cases a btdgiitg outwards of the
lower ribs over the liver points to the presence of
hydatid. A renal cyst has resonance in front, duo
to the colon. A histoiy of residence in Aostralia,
the Argentine, etc., should lead one to suspect
hydatid in cases of slowly increasing enlargement
of theliver.ufilA/eunjtieraymplom*. Exploratory
puncture is not justifiable, as it may set thescolices
free, which subaequently form multiple cysts. The
cyst fluid is pathognomonic . It is clear, opal-
eeoent. of low specific gisvity. and contains a
large excess of chlorides, no albumen {unless in-
flammation has token place), and — most charKc-
teristio of all — echinococcus booklets (see Fig. 74).
The blood shows eosinopbilia. and the serum gives
a specific pceoipitin reaction.

pTogtui*i».—VM patient may live for several *■!»■ 14,— Hooklots Irooi an Hidatid
years with no other symptoms than a alow increase ^^'^^^t^Tl.w

in the size o£ the liver. The prognosis must be timet. Ihaae lorm ths cro>rn of

guarded even if the cyst, whose presence has been hockieta uouod the aaleilor end

diagnosed, is safely removed ; for there may be °J, ^J!'°'''l^\"^ f!^^'i^

^i" 1 III ..I J I 1 .. . dlitlnctlvs of hvdstld Hold.

Other cysts present which will develop later. A jfjon, , photomlcrogrsph by

cyst may remain quiesoent for twelve years or Mr. Fredertck Clorlt.

more without dying or losing ite potentiality for

mischief. The cyst may suppuiste, giving rise to the symptoms of liver abscesSi or
pyeemia may be set up. When a oyst leaks into the surrounding tissues, symptoms of
acute poisoning occur — collapse, vomiting, and urticaria. Sometimes death occuib by
the sudden rupture of the cyst into the pleura or peritoneum.

The Trealmtnt is operative wherkcver possible. The cyst should be removed whole ;
if this cannot be done, it should be inoised and free drainage provided. This is
followed by the extrusion of the complete cyst wall is many coses. Every precaution
must be taken against soiling the surrounding tisanes.

Other rare causes of painless enlarqehent o{ the liver are chronic
blood diseases, noticeably leuk^xhia and splbnio an^^hia, cholxhia,
and kala-azas. Tduours (g 256} may not be accompanied by pain
in the early stages.

There aie three diseases in which enlargement of the livflt is attended
with pain and tendemen : I. Cebonio Congestiom, II. Cancer of thb
LtvER, and III. Abscess of the Liveb. In chronic cholelithiasis
and several acute disorders the liver may be slightly enlarged and t«ader.

368 THE LIVER [ §S 255, 26$

I. The enlargement is moderate^ smooth, and uniform^ painful, and
TENDER ; some jaundice and ascites may be fresent, the spleen is enlabOed,
and there are signs of congestion of the abdominal viscera. The disease is
probably Chronic Congestion op the Liver.

§ 2S6. Chronic Congestion of the liver is a condition in which the en-
largement is due to venous obstruction (passive congestion). Compare
the opening remarks in § 238.

Symptoms, — (i.) The liver is tender, and a sensation of weight and
fulness is complained of in the hepatic region. Expansile pulsation may be
conveyed to the palpating hand synchronous with the heart in the early
stages, but as the organ becomes firmer this is lost, (ii.) Signs of general
venous obstruction appear, (iii.) Ascites develops, and the spleen is
enlarged. The yellow discoloration of jaundice may arise, (iv.) Gastro-
intestinal disturbances are common.

Etiology. — Passive congestion is the result of any backward pressure
due to obstruction of the circulation. In most cases this is caused bv

heart or lung disease, and especially mitral valvular disease. Any growth
pressing on the inferior vena cava above the diaphragm has similar effects.

The Diagnosis is often aided by the recognition of the heart disease on
which it depends. In some cases of ascites with anasarca of the legs, we
may find both hepatic enlargement and albuminuria, and a difficulty may
arise as to which was the primary cause of the condition — heart, liver, or
renal disease. This difficulty is still further increased if extensive bron-
chitis prevents accurate auscultation of the heart. Now, in such cases,
the liver may be excluded as the primary cause, if the dropsy in the legs
clearly preceded the dropsy in the abdomen. The presence of hepatic
enlargement is then a sign of great value as helping to exclude renal
mischief, because enlargement of the liver is not a usual sequence of kidney
disease, although it is a fairly constant result of cardiac valvular disease.

Prognosis, — The prognosis is altogether influenced by the cause of the
congestion ; and the state of the heart is generally the measure upon which
the patient's chance of a longer or shorter life depends. In mitral stenosis
an enlarged liver with ascites is less grave than in mitral regurgitation,
because it normally occurs at an earlier stage in stenosis (Broadbent).
It is most serious in aortic disease, and especially regurgitation.

The TreatmerU is that of the cause, and our attention must be directed
to the heart and lungs. Purgatives and light foods are necessary in order
to relieve the strain on the portal system. Leeches over the liver or
bleeding may be indicated (see also Acute Congestion, § 238).

II. TAe enlargement o! the liver is irregular ; the pain and tenderness
may be great ; jaundice and ascites are present ; t?^ spleen is not enlarged ;
the patient is advanced in years, feMe and emaciated. The disease is
Cancer op the Liver.

§ 256. Canoer of the liver may be primary, but is usually secondary
to disease elsewhere; generally the stomach, rectum, or other part of
the alimentary canal.

§ 266 ] CANCER OF THE LIVER 369

Symptoms. — (i.) Pain is an almost constant feature of cancer of the
liver ; it is continuous, with exacerbations, and is independent of food or
position. A certain amount of tenderness develops, (ii.) The enlarge-
ment of the liver is irregular, and nodules may be made out. These are
of a hard consistence, and increase rapidly. There is also a less common
diffuse form of cancer in which there are no nodules, and in which the
liver is only slightly and uniformly enlarged. In the nodular form the
liver may be enormously enlarged, (iii.) Jaundice is usually present,
sooner or later, and is intense and progressive. An intense jaundice per-
sisting over five to seven weeks in an old person should indeed always lead
one to suspect cancer. Ascites generally occurs either from involvement
of the glands in the fissure, or the peritoneum.^ The spleen is not enlarged,
(iv.) The general health of the patient is bad, and emaciation and cachexia
may be present before any local signs are discovered. Cancer may be
present in another part of the body. Fever occurs at intervals, especially
in cases of primary cancer.

Causes, — Cancer occurs after middle life ; it is rare before thirty-five.
It is liable to occur secondarily to cancer of the stomach or rectum. When
a patient has been the subject of gall-stones for a long period of time, cancer
of the liver is apt to result in later life.

Diagnosis. — Jaundice is very rarely entirely absent in cases of cancer.
This and the cachexia alone may justify a diagnosis of the condition.
The diagnosis from cirrhosis may be difficult when nodular enlargement
cannot be definitely made out, and when considerable ascites is present.
In cirrhosis there is little or no pain and tenderness, the history of the
illness is of longer duration, the spleen is enlarged, and the jaundice is not
so intense. The inflammatory thickening under the liver after a long
history of gall-stones may resemble cancer, and can be distinguished
only when time shows little or no increase in the enlargement. Syphilitic
liver has not so much pain and tenderness, is of slower growth, and rarely
produces ascites.

Prognosis. — Cancer of the liver is usually fatal within six to twelve
months, death taking place from exhaustion. Untoward symptoms are
rapid growth, ascites, or respiratory difficulties due to extension of the
disease to the limgs.

Treatment can be palliative only. Morphia or opium is administered
for the pain, and attention must be given to the relief of the symptoms
of gastric distress, and to aid nutrition. With rest and care the patient
may have periods during which the disease makes no progress, and which
hold out to the patient false hopes of his ultimate recovery.

m. Abtoeis ot the Liver also produces considerable hepatic enlargement, which is

PAiKFUL and TEKDEB. It has already been described among the Acute Diseases,

§ 244 ; but sometimes it runs a very chronic course.

Tumours of the Liver, other than Cancsb (§ 266), Hydatid (§ 254), and Qitmma

251, Ic), are more rare. Their presence is manifested by enlargement of the organ.

^ Dr. 'Charles Murohison used to teach that jaundice with ascites in an old person
usually indicated cancer.

370 THE SPLEEN [ § M7

which may be regular or inegular, accompanied in some cases by constitutional
83rmptoms. When, as in some cases of Actikomygosis (§ 246), they assume an
inflammatory form, pyrexia, accompanied by sweatings and rigors, is present. Saboobia
OF THE LiVEB is occasionally met with — e.g., Lympho-sarcoma — ^but it is most often
secondary to deposits elsewhere, and the liver condition is only a subordinate part of
the case. The patient may be younger than in the other form of malignant disease.
Chondro-sarcoma, Melano-sarcoma, Tubercle, and Fibroma occur very rarely.

Floating Liver (Dropping or Ptosis of Liver, Hepatoptosis) is probably a somewhat
rare condition which is due to a laxity of the ligaments (vide the Lancet, May 12, 1900).
It is apt to be mistaken for enlargement of the organ, and vice verscL The condition
has been referred to under Abdominal Pain, because, if attended by symptoms, this
is the principal one. There may also be vague neurasthenic symptoms

THE SPLEEN.

There is still some doubt as to the precise part which the spleen plays
in the economy, and symptoms may be altogether wanting when it is
diseased. Great diminution in size of the organ has been found post-
mortem without any symptoms during life. When the spleen is removed
surgically or rendered functionless by disease, its duties are assumed by
the h»molymph glands and the lymphatic glands. What the duties of the
spleen may be are still matter for conjecture. The spleen does not appear
to have an internal secretion as do the thyroid, suprarenal, and pituitary
glands, but appears rather to suiSer as the result of disease elsewhere.
In embryonic life it is concerned with the formation of red and white blood
corpuscles. In certain of the ** blood diseases " in which it is enormously
enlarged it resumes these functions. It is also largely concerned in the
removal from the circulation of dead cells and of pigments, such as that
of the parasites in malaria. It enlarges during digestion, and owns muscle
fibres which give it the power of rhythmical contraction, the use of which
is unknown, but in all probability the spleen is in some way necessary to
the proper fulfilment of the digestive processes.

The spleen may be the seat of various congenital abnormalities. Of
these the commonest is the presence of accessory spleens ; less common
are multiple spleens and a multilobular organ.

PART A. SYMPTOMATOLOGY.

§ S57. In addition to the local pain and discomfort due to the enlarge-
ment of the organ, the symptoms which may arise include extreme paUor
of the skin, great toeahiesSy and aUerations in the Uood'CeUa^ chiefly
leucocytosis ; but we are not sure that all of these are results of splenic
disease. Thus in ''ague cake," for example, great enlargement takes
place without any symptom beyond the inconvenience due to the size of
the organ. In other instances a large spleen may, by simple pressure or
by the formation of adhesions, give rise to signs of disease in the neigh-
bouring organs^ especially the stomach. Pain and local tenderness
accompany acute enlargements, and there may also be pyrexia and
vomiting. The liver and spleen are often enlarged together ; one may
precede the other, or both may be results of a common cause. The

t$ 258, 859 ] PALPATION'-PERCUSSION 371

symptom which is found to be most constantly associated with disease of
the spleen is ancemia, the various causes of which are discussed elsewhere
(§ 401).

PABT B. PHYSICAL EXAMINATION,

§ 258. The only physical sign which can be relied upon as diagnostic
of splenic disease is enlargement of the organ, and this is most readily
made out by Palpation. When the spleen is enlarged, the anterior edge
of the organ, being free, makes its way downwards and forwards to%7ards
the umbilicus. The notch in the anterior border is so characteristic that
it forms a strong point in diagnosis of any splenic tumour. Method. —
Stand on the right side of the patient, who should be lying on his back.
Pass the left hand across the abdomen, and lay it posteriorly over the
eleventh rib on the left side, and place the right hand flat upon the anterior
surface of the abdomen, with the tips of the fingers just below the eleventh
rib. By gently dipping them down into the abdomen, and tilting the organ
upwards with the left hand during inspiration, the splenic notch may be
felt if the organ is enlarged. It is more readily palpated when the patient
draws a deep breath. Normally, the spleen cannot be detected by pal-
pation, and even slight enlargements may not always be appreciable.
An enlarged spleen always has a space between its posterior edge and the
erector spin© behind, into which the fingers can be dipped — at any rate,
in spare subjects. Fallacies, — ^Without being enlarged, the spleen is
readily palpable when it is displaced downwards, or is " floating." It is
sometimes displaced downwards in cases of deformed chest {e.g., rickets),
large pleuritic effusions, and emphysema.

§ 259. The Percussion of the spleen is attended with some difficulty.
The organ is situated in the left hypochondrium, between the upper border
of the ninth rib and the lower border of the eleventh ; and roughly between
the mid-axillary and scapular lines (Fig. 37, § 75). It extends obliquely
forwards and downwards nearly to the costal margin. It lies wholly
beneath the ribs, and the upper third is overlapped by the lung. Per-
cussion does not afford a very accurate means of investigation, but it is
well to remember that a straight line drawn from the centre of the left axilla ,
obliquely dovmtoards and forwards to the umhUiais, should be resonarU in its
entire length (Gairdner's line). The spleen normally lies altogether behind
this line, but if it be enlarged this line is impinged upon by dulness at the
junction of \\% middle and lower thirds.

The simvACE lakdmabk of the spleen may be said to form an oval, lying cbUqvely
between the post-axillary and mid-axillary lines, and having, for purposes of descrip-
tion, four borders. The procedure for percussing out the anterior and lower borders
differs from that used to elicit the upper and posterior, because the latter recede from
the surface, the lung intervening. It is best to percuss at the end of an expiration,
because the spleen is then less covered by lung. As mentioned above, palpation is
preferable, but to define the anterior and lower limits by percussion the patient should
lie on his back. (1) Anterior border — percuss lighUy along the tenth rib, starting at its
anterior end, and the note will be found to become dull about the mid-axillary line.
(2) For the lower border percuss, also lightly, along the posterior-axillary line from below
upwards, and the lower border should be reached about the lower edge of the eleventh

372 THE SPLEEN [ § 260

rib. (3) To define the upper and posterior limits is very much more difficult, and very
often — ^in fat subjects for instance — ^it is impossible. Fortunately, it is not of so much
importance to map out the posterior border. The patient must either sit up or lie in
a semi-prone position, resting on his right scapula. If he turns completely on to his
right side, the spleen may fall away from the left side. His left hand should be placed
on his head. Upper border — ^percuss with a heavy stroke just behind the post-axUlary
line, starting from the angle of the scapula and working vertically downwards. After
repeating this several times, it will be noticed that the pulmonary resonance is impaired
at the upper border of the ninth rib. (4) Posterior border — similarly with heavy per-
cussion, by starting over the neck of the tenth rib and continuing along that rib
anteriorly, you may elicit a change of note just in front of the scapular line.

FdUacies. — ^The dulness of splenic enlargemeni may be simulated by pleuritic efihision
or consolidation of the left. lung. The area of splenic dulness may be diminished by
emphysema of the lungs, or distension of the stomach or the colon by gas. The splenic
dulness may be altogether absent when there is a wandering spleen, or congenital
absence of tiie organ.

§ 2G0. Splenic Enlargements have three chief characteristics : (1) The
splenic notch is felt on its anterior border ; (2) the mass moves with respira-
tion if not bound down by adhesions ; (3) it is dull to percussion because
the resonant colon does not lie in front of splenic tumours, as it does in
front of renal tumours, Oairdner's line of percussion resonance (vOe supra)
being thus impinged upon. (4) When an area of dulness is due to splenic
enlargement, its outline resembles in sha'pe that of the normal spleen.

(5) It is distinguished from neoplasms of the peritoneum, stomach, intes-
tines, etc., by its smooth and firm surface. Irregular enlargements of the
spleen are rare, and can only be diagnosed after careful examination has
excluded disease of other viscera.

Splenic enlargements or tumours may have to be diagnosed from the
following conditions : (I) Renal tumours, and especially movable kidney,
in which there is resonant intestine in front of the tumour, and absence of
resonance in the flank ; (2) enlargement of the left lobe of the liver, in which
the dulness is continuous with that of the right lobe, whereas splenic
dulness rarely reaches to the middle line ; (3) cancer of the cardiac end of the
stomach, in which the dulness is less absolute, and there is coffee ground
vomiting, etc., and the splenic notch is absent ; (4) ovarian tumour, which
(i.) will have grown from below upwards, (ii.) the hand cannot be pushed
between the tumour and the pelvic brim as it can in the case of a splenic
tumour, and (iii.) can be felt on vaginal examination ; (5) accumtUation of
fceces, in which (i.) the tumour has an irregular outline, (ii.) doughy con-
sistence, and (iii.) a course of purgatives and enemata will remove it ;

(6) post-peritoneal tumour, in which (i.) there is no notch, and (ii.) no
resonance behind it ; (7) abdominal aneurysm, when of sufficient size to be
mistaken for the spleen, is attended by pain in the back, and evident
expansile pulsation ; (8) deep-seated abscess in the abdominal parieies is
tender, has a vague irregular outline, and is situated more superficially than
a splenic tumour.

§ 261 ] ENLABQEMENT OF THE SPLEEN 373

PART C, DISEASES OF THE SPLEEN.

§ 261. The diseases of the spleen are all — if we except the relatively
rare cases of wandering spleen and atrophy — comprised under the causes
of enlargement of the organ, and its diagnoBis therefore becomes a matter
of considerable importance. Enlargement is detected by palpation aided
by percussion as above mentioned. The mechanical effects of pressure,
when the spleen b very much enlarged, are mainly dyspnoea and gastro-
intestinal disturbance. These may be aggravated by attacks of peri-
splenitis, with acute pain locally, vomiting, pyrexia, and sometimes
diarrhoea.

The Causes of Enla^ement of the Spleen are most readily differentiated
according as they depend upon or are associated with the following :

I. Acute infections.
II. Chronic infections.

III. Portal obstruction or congestion.

IV. Blood diseases.

Y. Parasitic and tropical diseases.
VI. Infancy and childhood.
VII. Irregularity of the surface of the spleen.

Method of Procedure. — Ab pointed out in Part A., it is rarely that advice is sought
for symptoms directly pointing to a splenic origin. Frequently the spleen is found to
be enlarged when the patient is being examined for disease elsewhere. It should be
remembered that in some obscure maladies the detection of an enlarged spleen may
be an important clue to the diagnosis.

Inquiry should be made as to the msTOBY. Thus residence abroad suggests malaria ;
prolonged suppuration, lardaceous disease ; fever and rigors, the presence of some
pysemic cause.

The AGE of the patient is important (see VI. below) ; in childhood certain conditions
are common which are rare in adults.

The TSMPEBATTTRE aids the diagnosis of certain infections.

Examination of other organs may render the diagnosis easy. The condition of
the LIVER is of especial significance in several diseases. Thus a large liver, jaundice,
and a normal spleen point to gall-stones or cancer, but if the spleen as well as the liver
is large, these symptoms suggest cirrhosis or other obstruction. A very enlarged
spleen with but slightly enlarged liver suggests some of the " blood diseases ** which
can be accurately differentiated only by an examination of the blood.

I. Acute Infections. — ^Almost all acute infections are apt to be accom-
panied by slight enlargement of the spleen, and as far as the acute specific
fevers are concerned this is usually of little clinical significance. The
enlargement is especially found with typhoid and typhus fever, and
pneumonia. Sometimes, and particularly in typhoid fever, a splenic
abscess may complicate the original condition. In such a case local
symptoms of tenderness and pain will draw attention to the spleen.
Again, these sjmaptoms may arise in the course of some slight systemic
infection, and be due to suppuration supervening in the area affected by
an EMBOLISM or in some pre-existing cyst or tumour. Embolism due to
cardiac disease causes (i.) acute sudden pain, and (ii.) local tenderness due to

374 THE SPLEEN [ § 261

perisplenitis. Embolism due to pyflMnia is usually known by the presence
of the causal condition. In such diseases as leuksBmia, in which the massive
enlargement of the spleen is a prominent feature, the organ is liable to
attacks of acute capsulitis, which may give rise to difficulty in diagnosis
unless the possibility of their presence is borne in mind. A friction rub,
due to localised peritonitis, may be audible during the acute attacks.

The diagnosis of the cause may be very difficult, and the most accurate
balancing of probabilities may fail to reveal the truth. Expectant treat-
ment is then to be adopted, and consists of hot applications to the spleen,
rest in bed, and attention to the bowels. If the attack does not subside
and the local signs become worse, the advisability of surgical interference
must be considered. Fortunately this is rarely needed, and the attacks
tend to resolve in a few days, leaving adhesions which may lead to trouble
later (§ 257).

II. Chronic Infections. — (1) Malignant or Ulcerative Endocarditis
(§ 39a) may give rise to embolism, which causes acute symptoms, or to a
more chronic enlargement not wholly due to congestion, and difficult of
explanation. The symptoms in the latter case may be exactly similar to
those of splenic anaemia (§ 409), and may, moreover, occur when there is
not the least suspicion of cardiac trouble. The importance of this lies in
the fact that it is possible to remove the spleen with advantage to the
patient in splenic anaemia, but the operation would be inadvisable in
endocarditis. Abscess of the spleen may also occur in the course of this
disease.

(2) Syphilis may cause a uniform enlargement of the spleen in the early
stages of the toxaemia. Later, both spleen and liver may become enlarged,
and the diagnosis may be very difficult. Ascites may supervene, and
anaemia; If at the same time a degree of pyrexia be present for which no
cause can be found, syphilis is probably in operation.

(3) Tuberculosis may occur as miliary tubercle, as an abscess, as a
capsulitis, or even as multiple tuberculomata. In no case is it likely to be
diagnosed apart from the existence of tuberculosis elsewhere. It is rarely
primary in the spleen, and is then an exception to the rule ; if diagnosed it
might be operated upon. In some cases of splenic tuberculosis there is a
marked polycjrthaemia instead of the anaemia which usually accompanies
tuberculosis.

(4) Lardaceous disease of the spleen is becoming rarer every year. It
is known by : (i.) There is usually a history of syphilis, phthisis, or of
chronic purulent discharge ; (ii.) the liver shows signs of lardaceous disease,
and diarrhoea may be present, due to involvement of the intestines ;
(iii.) the spleen may be very large, much larger than is commonly the case
in acute or chronic infections.

(5) In the absence of fuller knowledge, Hanot's Disease (Biliary
Cirrhosis) may come under this heading. The spleen may be enlarged
before the liver in some cases. The diagnostic signs are considered
in § 251.

! 062 ] BLOOD DISEASES 375

III. Portal ObetraotUm or CongaittoiL — ^Any cause of portal obstruction,
of whatever d^ee, will naturally lead to congestion in the whole of the
splanchnic area, and in this the spleen will share. Thus the spleen is
enlarged in (1) oardiao and ohronio lung disease, with backward
pressure in the venous sjrstem. The obstruction may be more absolute,
as in (2) thrombosis of the inferior vena cava. In this case the enlarge-
ment of the spleen may reach a greater d^ee than in congestive conditions
of the liver, and where the thrombosis affects only the splenic vein the
hypertrophy may be extreme, and the sjrmptoms conform to those of
splenic ansemia (of which, according to some authorities, it is the chief
cause) (§ 409). (3) Cirrhosis of the liver (§ 250) is associated with splenic
hj^ertrophy. (4) In syphilitio fibrosis, however, the liver and spleen
are usually simultaneously affected. (5) One cause of splenic congestion
and hypertrophy must be mentioned, although of great rarity — viz,,
TORSiOK of the splenic pedicle. This is only likely to occur when the spleen
is displaced by its increased weight (in splenomegaly), or when it is pos-
sessed of an unusually long pedicle (as in splenoptosis and wandering
spleen). It is unlikely to be diagnosed except by operation.

§ 262. IV. ''Blood Diseases,*' or diseases of myeloid and lymphatic
tissue. This heading includes all those commonly known as *' blood
diseases." They merit individual remark, but for full descriptions the
reader is referred to other paragraphs. In almost all of these the acute
attacks of capsulitis above mentioned are apt to occur.

(1) Chlorosis is very often and (2) Pernicious Anemia not infrequently
associated with slight enlargement of the spleen. This never reaches a
large size, and the fact of its doing so would be a sign that the diagnosis
required revision.

(3) In SPLENO-MEDULLARY LEUKEMIA (§ 407) the Spleen is characteristi-
cally enormous, but it is to be remembered that in lymphatic leukemia
and in (4) ohloroma it may be just as large, even reaching 2 or 3 inches
to the right of the middle line. In the latter diseases some degree of
enlargement is almost invariable, and in the acute cases is always present.
These diseases are diagnosed largely by the blood examination.

(5) Hodgkin's Disease (§ 408) is known by : (i.) One or more groups
of enlarged lymphatic glands are present; (ii.) the splenic enlargement is
slight.

(6) Splenic Anemia (§ 409) could hardly be diagnosed without the
enlargement of the spleen, which usually reaches very considerable pro-
portions. As will be gathered from the remarks made above, this disease
is no doubt destined to be subdivided into several groups when further
knowledge is available. In the tropics it may be simulated by kala-azar
and other diseases. There is a form of splenic anaemia which is found
particularly in infants, and which has a tendency to occur in twins. In
this the prognosis is better than in the adult form, and there are blood
changes which serve to differentiate it.

376 THE SPLEEN £ $ 268

(7) Chol£Mia is associated with great enlargement of the spleen in the
majority of cases ; it is readily known by : (i.) It is a disease of family
incidence, and (ii.) the presence of jaundice (§ 233).

(8) Erythk^mia is diagnosed by (i.) polycjrthaemia, which may reach a
very high degree, and (ii.) the cyanosis, weakness, and parsesthesias to
which it gives rise (§ 27).

V. Troidcal Diseases. — The two most often met with are malabia and
KALA-AZAR. In acutc malaria the enlargement is not very great, but after
many attacks it may be enormous without giving rise to much inconveni-
ence. A history of attacks of ague occurring in a person who has been
abroad leads one to suspect the cause of the splenic enlargement ; but the
diagnosis is made only by finding the parasite in the blood. In kala-azar
the spleen usually reaches a large size, and is rendered the more prominent
by the emaciation of the subject. The diagnosis rests on the discovery of
the parasite in the blood (rarely) or in the material obtained by liver
puncture.

VI. In Infancy and Childhood rickets (§ 447) is one of the most frequent
causes of slight enlargement of the spleen which may depend on inter-
current catarrhs of mucous membranes. In children the spleen enlarges
much more readily than in adults, and for reasons which would not be
held adequate were an older person concerned. Congenital syphilis and
TUBERCLE are also more likely to be present in children, and are recognised
by signs of the disease elsewhere ; in syphilis the liver also is enlarged.
There is a special form of splenomegaly associated with ANiEMiA in infants
(§ 414), which has been mentioned above, and there is also a special form
of KALA-AZAR in infants. In cyanosis from congenital heart disease
there is sometimes marked enlargement of the spleen. Congenital
ERTTHRiEMiA is also described.

VII. Irregiilarity of the surface of the enlarged spleen. This gioup includes quite
a different class of disease to those above mentioned. The most important cause of
enlargement is sarcoma, for there is some hope of cure if the spleen be removed early
enough. It is rare, and usually occurs in cHldren or young adults. It can only be
diagnosed by exclusion. Other new growths are even more rare, and include lymphan-
gioma, fibroma, pulsating angioma (which may give rise to suspicions of aneurysm),
secondary cancer, and cysts such as dermoids.

Hydatid cyst in the spleen may be diagnosed by (L) the presence of marked
eosinophilia in a person who (ii.) has resided in an affected countiy, (iii.) the serum
reaction, and (iv.) sometimes by the presence of cysts elsewhere ; (v.) the cyst may
present the characteristic thrill on palpation. Lymphadenoma and the Gaucher
type of splenomegaly may give rise to irregular enlargement, and certain congenital
malformations are irregular.

The Treatment and Prognosis of splenic enlargement depend, for the most part, on
the primary condition. The treatment of lardaceous disease and of hydatid is givan
under Hepatic Disorders (§§ 253, 254). The treatment of " Ague Cake '' consists of
(i.) removal to a non-malarious district, and the administration of quinine and tonics,
with free saline purgation ; (ii.) unguentum hydrargyri iodidi dilutum, rubbed over
the splenic area, is a remedy which may be of value, (iii.) Violent movement
must be forbidden, as the spleen may rupture.

S 268. Wandering Spleen (Floating, Dropped, or Dislocated Spleen, Splenoptosis)
may be readily mistaken for enlargement of that organ when met with in the lesser

§264] ATROPHY OF THE SPLEEN 377

degrees of displacement. But when the dislocation is, as generally happens, consider-
able, it is more often taken for a floating kidney. However, the presence of the notch,
the fact that it can be made to recede upwards and that it comes down in front of the
colon, aid in the diagnosis. The condition is mostly met with in multipars with
pendulous abdomens. It may be accompanied by nervous symptoms, though these
are less constant than in dislocation of some of the other viscera. If troublesome, the
condition may be relieved by removal of the organ, an operation which has been
performed several times with good results.

§ 264. Atrophy of the Spleen is, as a rule, unattended by symptoms. It is, as
Bristowe said, a condition not infrequently met with. It may be congenital, but its
commonest causes are : I. Cirrhosis of the spleen, due to an increase in the interstitial
tissue, the result, as in cirrhosis of the liver, of alcohol ; and II. Ck)NTRAonoN or
THB FiBRons GAPSULB, usually of Syphilitic origin. The syphilitic deposits in the
capsule of the spleen sometimes take on a cartilaginous change, and form plates of
cartilage. I have come upon them several times in the dead-house, but they had
been unattended by symptoms during life. I have also met with some five cases
of marked atrophic condition of the spleen, without symptoms during life, death having
occurred from independent causes.

CHAPTER XIII

THE URINE

The intricate subject of renal diseases is rendered more comprehensible
by a brief consideration of their history. In 1812 Wells^ foimd that
albumen in the urine was associated with certain forms of dropsy. It was
not, however, imtil 1836 that Bright ^ went a step farther and discovered
that dropsy and albuminuria, when associated together (in the absence
of heart disease), were indicative of disease of the kidneys. The term
" Bright's disease " has thus come to be synonymous with disease of the
kidney. We now know that there are many different disorders of the
kidney which present dropsy and albuminuria at some stage of their
course. Thus, we have acute inflammation of the renal epithelium, and
this is known as Acute Bright's Disease. Similarly, the term " Chronic
Bright's disease " should, in the author's judgment, connote chronic renal
disease, of which there are at least two distinct clinical varieties — chronic
tubal nephritis and chronic interstitial nephritis. But the term " Chronic
Bright's Disease " has, in later years, sometimes been used to indicate
only the last-mentioned variety. Now chronic interstitial nephritis — t.e.,
the granular or gouty kidney — is very generally associated with a wide-
spread cardio-vascular change in which the high blood-pressure and its
general symptoms are more pronounced than the urinary sjnnptoms. By
degrees the term Chronic Bright's Disease came to be applied to cases in
which the chief and perhaps the only symptoms were cardio-vascular.
Even since it was shown that high blood-pressure and cardio-vascular
changes may occur without renal disease,^ the term Chronic Bright's
Disease is still sometimes loosely and incorrectly applied to high arterial
pressure and its associated symptoms.

Renal diseases are for the most part chronic, and often obscure ; but,
with a knowledge of these historical data, their study would be com-
paratively simple were it not for another confusion which has arisen owing

^ Wells, Transactions of the Society for the Improvement of Medical and Surgical
Knowledge, iii., 194, London, 1812.

' Bright, Guy's Hosp. Rep., I., London, 1836.

^ The author's investigations into the large series of renal cases on the one hand and
cardio-vascular cases on the other which presented themselves at the Paddington
Infirmary revealed this (Trans. Med. Soc, London, 1897-1898; the Lancet, 1897.
vol. i., pp. 882 and 1235 ; Brit, Med, Jaum,, January 23, 1897 ; and Trans. Path.
Soc., London, 1904).

378

§! 865, 266 ] SYMPTOMS OF KIDNEY DISEASE 379

to the numerous terms applied by pathologists to diseases whioh difier
anatomically, though not always clinically. In what follows we shall be
concerned only with the clinical aspect of renal disease.

It is not always possible in practice to separate kidney diseases proper
from disorders of other parts of the urinary tract, because changes in
the urine are common to them all. It will be necessary, therefore, to
refer to disorders of the bladder, prostate, and urethra for diagnostic
purposes, though their treatment comes mainly within the province of
the surgeon.

PART A, SYMPTOMATOLOGY.

§ 265. The chief function of the kidneys is the elimination of nitrogenous
waste. When this is interfered with by structural or functional disease,
a toxic condition results, which, when it reaches a certain stage, is known
as uraemia.

As a consequence of the deep-seated position of these organs, the local
symptoms referable to the kidney are, except in cases of Tumour or dis-
placement, of subordinate importance. The most constant and cardinal
SYMPTOM of kidney disorders is some Alteration in the Urine, which, as an
indication of renal disease, corresponds to the physical signs in other
organs, and is dealt with in Part B. of this chapter. The cardinal symp-
toms next in order of importance are Pallor of the Surface and Dropsy.
General symptoms, due to the toxic state which results from the retention
of the nitrogenous waste, also accompany these diseases.

Pallor of the Surface and Malaise are very constant features of all
organic kidney diseases. To the experienced eye the pallor differs from
that of anaemia in a manner somewhat difficult to describe. The skin has
a " waxy " hue, a simile which is still further exemplified when dropsy is
present. It affects the whole body, but is always most evident in the
face. In chronic interstitial nephritis the pallor has a greyish hue. The
diagnosis from other causes of pallor will be foimd in Chapter XVI.,
§401.

§ 266. Renal Dropsy is of general distribution, in which respect it differs
from cardiac dropsy, which starts in the legs or most dependent parts,
and from hepatic dropsy, which starts in the ctbdomen. It is, however, most
evident in the loose cellular tissue — e.g., around the eyelids, where it is
most marked on first rising in the morning. Towards evening the ankles
become oedematous, or, as the patient may express it, a " ridge is present
around the top of the boot." In severe cases (e.g., in acute nephritis)
the eyes may be almost closed by the swollen lids, and at the same time
there may be signs of dropsy in the serous cavities — the pleura, peritoneum,
and pericardium. CEdema of the solid organs also occurs in severe cases,
and death may be produced by pulmonary oedema. (Edema glottidis is
another serious though less frequent complication.

Dropsy is by no means an equally constant feature in all diseases of
the kidney. In acute and chronic farenchyriMUous nephritis {i.e., disease

380 THE URINE 11267

in which the renal epithelium is primarily affected) dropsy is almost in-
variably present. But in chronic interstitial nephritis and lardaceous
kidney it is comparatively rare ; in the former it may occur late in the
course of the disease, when it is generally due either to cardiac failure or to
secondary inflammation of the renal epithelium. In uncomplicated
pyelitis and neoplasms dropsy is not present.

§ 267. A large number of General Symptoms occur as the result of the
retention of the nitrogenous waste products : Cardio-vascular changes,
haemorrhages, breathlessness, affections of the nervous system, ocular
changes, gastro-intestinal disorders, and secondary inflammations.

Cabdio-vasculab Changes frequently accompany renal disease. In acute and
chronic renal disease there is usually high blood-pressure, and often dilatation of the
heart. The accentuated second aortic sound which accompanies this high pressure
is a useful indication in some cases for bleeding, or other measures for the reduction
of arterial tension. In chronic interstitial nephritis the high pressure is apt to he
followed by a thickening of the arteries due to hypertrophy of the muscular coat.^
The left ventricle becomes hypertrophied, and, in the later stages, signs of cardiac
dilatation and failure may ensue.

H^fiMOBBHAOES sometimcs occur in chronic Bright*s disease, a consequence of the
high pressure, combined in most cases with a diseased state of the bloodvessels.
Epistazis, for instance, may be the first symptom which leads to the discovery of
clm>nio Bright*s disease. Bleeding from the stomach or intestines, and purpura,
sometimes occur. Cerebral hiEmorrhage is afreqtient cause of decUh,

Bbbathlbsskess, apart from that due to chronic pulmonary oedema, is a common
accompaniment of renal disease. Renal disease is the most frequent cause of acute
pulmonary oedema. A paroxysmal dyspnosa, coming on during the night in a person
of advanced life, should lead us to suspect the existence of chronic Bright's disease,
even although the patient may continue his occupation. Cheyne-Stokes respinUion
may develop towards the end, with or without other symptoms of ursemia.

Nebvous Symptoms are not infrequent, apart from the cerebral hssmorrhage just
referred to. Thus, Jieadciche is a symptom which accompanies all renal diseases,
particularly those forms which terminate in ureemia. Experience among the aged
shows that chronic interstitial nephritis is one of the most frequent causes of headache
in advanced life. The patient may continue his work, and present no other symptom,
but an examination of the urine may reveal the existence of chronic renal disease.
Vertigo, tinnitus, and various neuralgias may also be complained of. Insomnia in the
aged is another common symptom of chronic renal disease. The i>atient complains
that he readily drops off to sleep, but as readily awakes, and that he may do so ik
dozen times every night. As the uremic condition, increases, however, droujsiness
supervenes, which may pass into coma, with or without muttering delirium. Some-
times convulsions occur before death.

OouLAB Chanqes frequently accompany renal disease attended by albuminuria ;
and so characteristic are the changes that albuminuria may be diagnosed by their
presence. Albuminuric retinitis comprises alterations in both fundi— csdema and
swelling of the retina, papillitis, flame-shaped haemorrhages into the retina, and white
spots of fatty degeneration. Changes in the arteries may also be seen.

Gastbo-intestinal symptoms attend some renal diseases. Thus dyspepsia and
irregularity of the bowels are common. Vomiting, when persistent, is a symptom of
considerable gravity, because it is usually of toxic — i.e., ursemic— origin.

^ As Dickinson and BoUeston have shown in the Lancet, July 20, 1895. See also
Arterial Hypermyotrophy, § 68. With certain methods of preservation and hardening,
or with insufficient staining, the middle coat presents precisely the appearance of
fibrous tissue ; but well-stained logwood preparations always reveal the rod-shaped
nuclei, and acid orcein ^nll always reveal the elastic tissue boundaries of the tunica
media.

§§268-270] PAIN IN THE KIDNET^UBjBMIA 381

§ 268. The Complicatioiui and Secondary TnflamTnationi in renal cases
are very apt to aSect the serous membranes, the mucous membranes,
and the skin — in a word, the limiting or " surface " structures of the body.
The seroiM membranes often become inflamed insidiously, especially the
pleura and pericardium. The effusion may sometimes come on very
suddenly, but the symptoms may be quite latent ; therefore the occur-
rence of severe d3^noea in renal cases should lead us to suspect the
sudden supervention of a serious pleural effusion (§ 21). In addition to
the jndmonary cedema already mentioned, a low form of pneumonia or
bronchitis is a conmion complication of nephritis. Endocarditis is rela-
tively rare. Within the last few years it has been recognised that renal
disease may be complicated by various skin affections other than dropsy
and the cellulitis which is liable to affect dropsical limbs. Amongst these
may be mentioned eczema, urticaria, and various forms of erythema.
Undoubtedly the most fatal is an epidemic form of exfoliative dermatitis
described by the author in 1891.^ All the cases of renal disease com-
plicated by the epidemic exfoliative dermatitis which the author has since
met with, have ended fatally.

§ 269. Pain in the Kidney. — Many serious diseases of the renal substance are tm-
accompanied by any pain or local symptoms. A sense of dull aching in the loins may
be present at the onset of acute nephritis. In pyelitis, lumbar pain generally accom-
panies the appearance of pus in acid urine. The pain is very severe when the pyuria
(pus in the urine) is due to a renal calculus (Renal Colic, § 301). Various tumours of
the kidney are accompanied by pain, and perinephric abscesses are associated with
lumbar pain and tenderness. A dull, dragging pain or weight in the lumbar region,
relieved by rest in the recumbent posture, occurs with movable kidney ; it is usually
on the affected side, and is liable to acute exacerbations resembling renal colic. The
lumbar pain of renal disease must not be mistaken for the backache due to congestion
of the female generative organs, nor for lumbago, in which the pain is usually of sudden
onset, is not confined to one side, and may be accompanied by other rheumatic
evidences. Less frequent causes of lumbar pain are aneurysm, cancer, and caries
of the vertebrsB.

§ 2170. UiaBmia is a term used to describe the group of symptoms which
arise from retention within the body of those nitrogenous constituents
which, under normal circumstances, are elaborated into urea and eliminated
by the kidney. The exact nature of these retained substances is not yet
known. The term uraemia b generally used for the intense acutely toxic
condition which closes most renal cases ; but it may also be applied to the
incipient or chronic condition which precedes this, and warns the observant
physician of the gravity of the situation. It is the evidence of retention
in the blood and the tissues of those substances which form a chain of
compounds between the proteid food substances and the nitrogenous
disintegration on the one hand, and the nitrogenous output on the other.
Thus, uraemia may arise in many hepatic diseases (defective elaboration),
and in many renal disorders (defective excretion).

Ursemia, more or less severe, may occur in almost any disease of the
kidney. In renal fibrosis (granular kidney) it occurs in a typically chronic

^ Trans. Med. Soc, London, 1891-1892 ; and British Journal of Dermatology, 1892.

382 THE URINE [§870

form ; in acute, subacute, and chronic tubal nephritis it is the usual
mode of death ; in tuberculous; calculous, and cystic disease, in hydro-
nephrosis and consecutive nephritis, in active or passive congestion, and
in lardaceous disease (rarely), mentioned in order of frequency, it is also
apt to supervene. Moreover, complete suppression of urine may produce
death associated with S3rmptoms of what is called latent urcBmia (§ 311),
in those relatively rare cases of blocking of the ureters.

Symptoms, — ^Various forms (nervous, gastro-intestinal, dyspnoeic, etc.)
of ursBmia are sometimes described, but it is more convenient and not more
artificial to describe the symptoms under indfient and advanced chronic
uraemia, and actUe uraemia.

1. In incipient chronic uraemia, such as occurs typically in chronic inter-
stitial nephritis, the symptoms are vague, and start insidiously. The
patient remains at work, but complains of malaise, loss of mental and
bodily vigour, general wasting of muscular and subcutaneous tissues,
impaired memory, and sometimes sleeplessness after the first few hours of
the night. These and the urinary changes may be the only indications
of the condition.

2. Sjrmptoms of advanced chronic uraemia may succeed the foregoing,
or may come on abruptly in a person apparently in good health. They
consist of (i.) restlessness and muscular tremors (which constitute one of
the most constant s3anptoms) ; (ii.) persistent headache ; (iii.) drowsiness
during the day, with sleeplessness or " cat-sleeps " (dropping off for a few
minutes at a time) at night ; (iv.) vomiting, without obvious dietetic
irregularity or gastric disturbance, and sometimes diarrhoea ; and
(v.) dyspncBa on slight exertion (which is often the first symptom to be
noticed), or coming on in paroxysms, especially at night. Uraemic
Dyspnoea may be : (i.) Paroxysmal ; the attacks coming on chiefly at night,
and resembling asthma. The patient sits up in bed gasping for breath, but
there is no cyanosis, and the mind is clear. The breathing is often noisy,
with a characteristic hissing quality (Addison), (ii.) Continiums, or con-
tinuous alternating with paroxysmal, (iii.) Cheyne-Stokes Respiration
may last for weeks. The pulse slows in the apnoea period, and there is
alternate contraction and dilatation of the pupil, the contraction occurring
during the period of apnoea.

3. Acute or fulminating uraemia may supervene at any stage of the
foregoing, being ushered in by an increase of the headache, vomiting, or
restlessness ; or it may come on abruptly in an apparently healthy person.
Its leading symptoms are three : (i.) Low muttering delirium ; (ii.) stupor,
passing into coma, with or without (iii.) convulsions. The patient may
pass from convulsions to coma, and again to convulsions. In some cases
of chronic Bright's disease convulsions or coma may constitute the first
manifestation of the disease.^ Sometimes blindness (uraemic amaurosis),

^ This is explained by a sudden congestion of a chronically diseased kidney, and
such cases (coma or convulsions occurring suddenly in an apparently healthy person)
usually occurred during the winter in the Infirmary.

§271] EXAMINATION OF TEE URINE $83

without appreciable ophthalmoscopic changes, follows the convulsions,
and may last for several dajrs. Deafness or local paralyses may ensue.
There is often a urinous odour in the breath.

Diagnosis, — Ursemia is known by the combination of these symptoms,
and the presence of a cause, which can be made out on a careful examina-
tion of the urine. The diagnosis of uraemic coma is dealt with in
Chapter XIX., § 530.

The Tre€UmerU of urcemia is given under Chronic Bright's Disease (Con-
tracted Granular Kidney) (§ 297), in which malady both chronic and acute
uremia typically occur.

PART B. PHYSICAL EXAMINATION,

The Ezaminatioii of the Urine corresponds, in renal diseases, to the
physical examination of other organs. We examine it by (a) observing
its physical characters (§ 271) — ^viz., its appearance {i.e,, its colour, and
whether it is clear or cloudy) — its odour, reaction, specific gravity ; the
presence and characters of any deposit ; and its diurnal quantity, (b) Then
by chemical analysis (§ 276) we ascertain the presence or absence of albu-
men, the presence or absence of sugar, and other substances, according
to circimistances. (c) Finally, a microscopic examination (§ 289) has to
be made of any deposit which may be present. It is important in all
cases — not only in cases of suspected renal disease — to observe and to
note the condition of the urine when the patient is first seen, even when
the symptoins do not suggest renal disease.

(a) Physical Characters of the Urine;

§ 271. Appearance. — The colour of the urine depends upon the proportion of pig-
ments present. The chief pigments are urobilin and urochrome, whose antecedents
are the blood and bile pigments ; but there are many others.

The urine varies from a pale yellow to a deep amber, according to the degree of
DILUTION of the pigments ; and, as the latter are fairly constant in quantity, a dark
urine is associated with a smaller diurnal quantity and a higher specific gravity than
a pale urine. The urine is dark in excessive perspiration, acute nephritis, and pyrezial
states generally. On the other hand, in certain diseases with polyuria the urine is
pale, as in chronic Bright's disease, and in diabetes. In diabetes insipidus and
hysteria the urine may be as colourless as water.

The colour of the urine may be altered by morbid products — e.g., a dark orange
colour to hroum, having a greenish tint on the surface with reflected light, is due to the
presence of bile, and will vary in depth of tint according to the amount of bile present.
A red colour, which may be a dark red or porter colour or only a mere ** smokiness,*'
is due to the presence of blood (§ 283). In diseases in which there is destruction of the
red blood corpuscles the urine is darkened, and this may be a means of distinguishing
pernicious ansemia from chlorosis. Blackish-hroum colour may be due to melanin
and certain oxyacids, which cause the urine to darken on exposure. A bright green
urine may be associated with chloroma. Milky urine is found with chyluria and
multiple myeloma. Various drugs affect the colour of the urine. A dark olive-green
or black colour may be due to the absorption of carbolic acid — as, for example, when
this substance is used for dressings ; or it may appear after the administration of
creosote, the salicylates, salol, tar, resorcin, or naphthol. The colour is explained b^
the presence of hydroohinon, which turns crimson on the addition of ferric chloride.

384

THE UJRINE

[K 272-274

A reddish-brown colour may be due to rhubarb, senna, or chiysopbanic acid when
taken internally, and a bright yeUow colour follows the administration of santonin.
All these turn red on the addition of an alkali. A colourless urine is said to result
from tannin taken by the mouth, and a reddish hue from logwood. The urine may be
red after the application of Scarlet Red ointment to superficial sores. Coloured sweets
and cakes may cause a coloured urine, from the presence of eosin, methylene blue, or
other dye. Black urine may also follow the ingestion of black cherries or bilberries.
Urinary Deposits and Cloudineu will be described in § 288.

§ 272. Reaction. — The urine should be tested immediately or soon after being
passed. In normal urine an acid reaction is found, turning blue litmus paper red,
from the presence of acid phosphate of sodium. On standing for a time decomposi-
tion takes place, the urea being transformed into ammonium carbonate (NH2)2CO+
2H20=(NH4)2C03. and hence the reaction is alkaline. The same change takes place
even within the bladder, in cases of chronic catarrh of that organ. Alkalinity due
to a fixed alkali occurs even in normal urine after meals, or when a patient is undergoing

alkaline treatment. A neutral reaction may occur under the
same conditions. It is sometimes important to distinguish
between the alkalinity due to a fixed alkali {e.g,, soda or
potash salts), and that due to decomposition, which depends
upon a volatile alkali (ammonia). This is done by holding
over a flame the red litmus paper which has been turned
blue ; if due to a volatile alkali, the red colour will return
(as the volatile alkali is driven off) ; if to a fixed alkali, the
blue colour remains.

§278. Specifle Gravity. — The average specific gravity of
the urine varies between 1015 and 1025. It depends chiefly
upon two substances normally present : urea and salts
(especially chlorides) ; and the simple rule of doubling the
last two figures gives roughly a little less than the total
quantity of solids present in parts per thousand. Extrac-
tives and pigment play only a small part ; and practically —
since the salts are fairly constant — ^the specific gravity, in
the absence of sugar, gives us a fair measure of the urea
present in a given sample. The specific gravity must be
considered in relation to the quantity of urine passed ; and
Yig. 76. — Urinombtbr, to be able to draw accurate inferences from the specific
made of metal, and gravity, the urine of a whole day should be collected, and
w^lf^by ' Hide? a sample thereof tested (§ 276). The mstrument used to test
of Hatton 6arden| ^^^ specific gravity is called a urinometer (Fig. 76). It is

convenient to have a metal one with a flanged foot, as
shown. The instrument must not touch the sides of the
vessel, and the graduated stem should be read along the
surface of the fluid, not at the place where it is raised along
the stem by capillarity. These instruments are graduated
for a temperature of 60° F. If the temperature of the urine is lower than this, the
true specific gravity is a trifle lower than the actual reading.

When enough urine is not obtainable, and a glass bead urinometer is not
accessible, mix the urine with one, two, or three times its own bulk of water
and multiply the last two figures of the specific gravity by two, three, or four
respectively. For example, a mixture of one ounce of urine with three ounces of
distilled water gives a specific gravity of 1005 ; the specific gravity of the urine was
1020(0-005x 4=0-020).

§ 274. The normal odour of freshly- passed urine is described as " aromatic " ; it is
very different from the ammoniacal odour of decomposing urine. The resinous por-
tions of copaiba, cubebs, and other balsams are excreted by the urine, and impart
their characteristic odour to it. Turpentine gives to urine an odour said to resemble
violets. It may smell of volatile sulphides due to the presence of some microbes,
notably B. colt communis, and also where cystinuria is present, especially after tho
urine has stood for a little.

B.C.).— The flanges
steady it while in the
urine, and form a
stand when not in
use.

S§ 876, 276 ] THE DIUBNAL QUANTIf Y-^ALBUMM 386

§ 275. Tlie Diurnal Qaantity varies considerably within the range of health. Nor-
mally, 40 to 50 ounces (IJ litres) are passed per diem, but the quantity depends upon
the amount of fluid drunk, the action of the skin, and the activity of the renal circula-
tion. In order to estimate the quantity of urea, and for some other purposes, it is
necessary to collect the whole of the urine that is psissed in twenty-four hours — say,
for example, from 8 a.m. Monday to 8 a.m. Tuesday. The patient should pass water
ai 8 a,ni. on Monday morning, and this should be thrown away. Then all that is
passed after that hour, together with what is passed cU 8 a,m. on Tuesday should be
collected in one dean vessel, which must be carefully preserved from accident or
interference. During the whole of that time it is necessary to pass water before going
to stool, and to add this to the total collected. At 8 a.m. on Tuesday, after passing
water and adding it to that previously passed, the whole should be stirred and measured.
A specimen from this should then be put into a clean bottle (say, 10 ounces), and this
should be labelled with the name of the patient, the date, and the total quantity passed
in twei|^y-four hours, and sent for examination immediately.

(h) Chemical Examination of the Urine,

Normally the urine consists of water containing about 4 per cent, of
solids by weight, of which urea, the most important, comprises from
2*5 to 3 per cent, of the total uriae, amounting to about 30 granmies
per diem.

In disease the three most important substances for which the urine
has to be tested chemically are albumen, sugar, and urea.

§ 276. Albumen is the most frequent of the pathological constituents of
the urine. The variety of albumen usually present is serum albumen.
(The other forms are given below.)

The chief tests for albumen are : (1) Cold nitric acid ; (2) Boiling ;
(3) Picric acid.

1. The Cold Nitric Add Test^ is the most delicate, accurate, and con-
venient test for small quantities of albumen in the urine. Pour some
strong nitric acid into the bottom of the test-tube, hold the tube in a very
sloping position, and let the urine gently flow upon the top ; a haze of
precipitated albumen will appear at the line of junction. It is necessary
to wait a few seconds for the haze to appear, when the albumen is very
small in quantity ; and the tube should be gently heated at the junction.

The Fallacies of this test are not serious, (i.) Mucin, or urates, may form a precipi-
tate, but it occurs above the line of junction ; (ii.) in a concentrated urine, a haze of
tiny crystals of nitrate of urea may form, but this may readily be dissolved by heat ;
(iii.) copaiba and other resins give a haze in a simHar position, but the odour is
characteristic ; (iv.) the haze due to the presence of albumoses disappears on heating,
and reappears on cooling ; (v.) both pus and blood contain albumen, and if present
in the urine, give this reaction, apart from the presence of free albumen.

2. Boiling, — After testing with litmus, boil the iirine, and afterwards
add a drop or two of acetic acid. A generalised white precipitate forms on
boiling if albumen is present, and is not dissolved by acetic acid. It is
always best to boil the upper part of a column of urine so as to compare
it with the lower.

^ If HNO3 is not handy, a saturated solution of common salt, carefully poured down
the side of a test-tube containing albuminous urine, gives a haze at the line of junction.
But cold nitric acid was decided by a Committee of the Clinical Society of lK>ndon to
be the best ail-round test for albuminous urine.

380 THE URINE [K 277-279

Where no test-tube is available at the bedside, it is useful to remember
that the urine may be boiled in an iron spoon, and a little vinegar used
instead of acetic acid.

The Fallacies of this test are : (i.) Phosphates may be precipitated by heat alone if
the urine be faintly acid, neutral, or alkaline, but the acetic acid dissolves these and
increases the albuminous precipitate, (ii. ) Excess of acid may redissolve the albumen ;
undue natural acidity may have the same effect, all of which prove the usefulness of
test-papers, (iii.) In acid urines a cloud sometimes appears, not on boiling only, as
albumen would do, but when the acid is added, due to mucus, (iv.) Copaiba and other
resins may give a precipitate insoluble in acid, but their odour is characteristic,
(v.) If the urine is not quite clear, it may be necessary to filter it, if boiling the
upper part of the tube gives us no information. If turbid from bacteria, add a
trace of NaOH, and a deposit of phosphates occurs which carries the bacteria down
with it. •

3. Picric Acid Test. — float carefully a saturated solution of picric acid on the urine
by a pipette. A precipitate forming at the line of junction of the fluids indicates the
presence of albumen. Urates, alkaloids, and albumoses may also be precipitated, but
disappear on heating.

The guanHtfxHvt estinuUion of albumen may be roughly determined by boiling as
above and setting aside the test-tube for twenty-four hours, and reading off the pro-
portion. It may be more precisely calculated by means of £sbach*s albuminometer, a
tube graduated for measuring the percentage of albumen. Urine taken from twenty-
four hours' collection is poured into the tube up to the mark U, and the reagent^ is
added up to the mark K. The tube is then set aside for twenty-four hours, and the
precipitate falls to the bottom. The level to which this reaches is then noted, and the
number on the glass indicates the grammes per litre of albumen present. Fallacies. —
(1) This method is not reliable if the specific gravity of the urine is over 1010. The
urine should be diluted to 1010, and a calculation made afterwards by multiplying the
result by the number of times of dilution. (2) If the patient is taking alkidine salts,
crystals are liable to appear after adding the reagent, and these must be allowed for
in reading off the quantity of albumen. Another method is precipitation by boiling,
washing the precipitates and weighing.

§ 277. Mucleo-proteid occurs sometimes in febrile disorders and in association with
destruction of the kidney cells. It gives most of the tests for albumen, but is precipi-
tated on the addition of acetic acid. From mucin it is distinguished by the fact that
it is soluble in a large excess of aoetic acid, whilst mucin is not.

§ 278. Mucin is precipitated, as above mentioned, by most of the same reagents as
albumen, but it may be detected by taking a saturated solution of citric acid in a test-
tube, and trickling the urine down the sloped side of the tube, when a cloud forms
above the junction of the fluids. Excess of mucus indicates irritation of the bladder
or genito-urinary tract, or a vaginal or uterine discharge.

§ 279. Sugar (Gluoose) is not a normal constituent of the urine, but it
may occur as a permanent or temporary pathological product. The chief
cause of permanent glycosuria (sugar in the urine) is Diabetes Mellitus
(§ 309). It should be remembered that the sugar may disappear from the
urine in this disease for some days, and reappear again as abundantly as
before. Transient glycosuria is found with errors of diet, excess of carbo-
hydrates, usually in gouty people. Its numerous other causes are referred
to in § 308.

Tests for Glucose. — (1) Trofnmer's Test constitutes one of the readiest for dis-
covering sugar. To an inch of urine in a test-tube add one-eighth its volume of
caustic potash and a few drops of a solution of copper sulphate. On boiling, a red
precipitate denotes the presence of glucose.

^ Picric acid, 1 part ; citric acid, 2 parts ; water, 100 parts.

S270] 8VQAR 387

(2) Fehling'a Test, — Fehling's solution consists of an alkaline solution of potassio-
tartrate of copper, so prepared that 10 c.o. is reduced by 0*05 gramme of glucose.
As it is apt to alter on keeping, it should be boiled before using, to make certain that
no precipitate forms before adding the urine. It is better to keep the copper solution
and the alkali solution in separate bottles, mixing them just before using. Add to it
a few drops of urine and boil again ; and then continue adding till equal quantities
of urine and Fehling are used. If on further boiling the solution is still clear, no
noteworthy quantity of sugar is present. The Fehling's solution must always be in
excess, and the boiling must not be too prolonged. This test depends upon the fact
that glucose has the property of reducing cupric salts when heated in the presence of
a free alkali. CUSO4 added to NaOH causes a pale blue precipitate of hydrated cupric
oxide. If a tartrate is present, the cupric hydrate is held in solution (Fehling's solu-
tion). If glucose or some other readily oxidisable substance is added, this blue cupric
hydrate on gently heating is reduced, and falls as a red or ydlow precipitate of cuprous
hydrate (Cu^O, H2O), which on longer boiling becomes red or purple cuprous oxide
(CujO).

Fallacies. — (i.) The urine to be tested must be freed from albumen, and (ii.) it must
not be ammoniacal. (iii.) Other reducing agents may occasionally give the reaction.
After the administration of chloroform, chloral, morphia, curare, and some other
drugs, a reaction is obtained resembling that due to sugar, but is due probably to the
presence of glycuronio acid. Lactose, uric acid, and urates, ammonium chloride,
and other ammonium salts, hippuric acid, kreatinine, oxyacids and the products of
certain drugs, such as carbolic or benzoic acids, may occasionally be sources of fallacy.
To avoid these it is best to control by the Fermentation Test, or to filter a few drachms
of the urine through a charcoal filter seven or eight times, by which means all reducing
substances other than sugar are removed.^

Quantitative Estimation by Fehling's Solution. — The urine should be a sample taken
from the total collection of twenty-four hours. Fill a burette with urine diluted to
I in 20, and have 10 c.c. Fehling's solution in a porcelain dish, diluted with water.
Boil the solution, and while boiling allow drops of urine to mix with it, stirring all the
while. Urine must be run in from the burette till the fluid is colourless ; this is difficult
to decide unless the dish be tilted so that it shows against the white background apart
from the red precipitate which collects at the bottom. Read off the amount of urine
required for complete reduction and calculate. Supposing we find that 60 c.c. diluted
urine from the burette are required to decolourize the 10 c.c. Fehling (representing
0-05 gramme glucose), then *l^=^ c.c. urine contain 0*05 gramme glucose. Then
from this, as we know the number of c.c. urine passed by patient in twenty-four hours,
it is easy to calculate the percentage of sugar excreted in that time. Carwardine's
Saccharimeter (Fig. 76) may be employed in this process if an ordinary burette, as used
in the laboratory, is not accessible.

(2a) The Ammoniated Cupric Solution (Pavy's Test) is a modification of Fehling's
solution. It contains free ammonia, and this keeps the oxide in solution, which would
otherwise be precipitated by the addition of diabetic urine. Hence the Uue colour of
the fluid is discharged without the formation of any precipitate, and it is thus easier to
determine the exact point when the whole of the cupric salt is reduced than is the
case when Fehling's solution is employed. Pavy's solution (10 c.o. of which represent
0*005 gramme of sugar) is therefore very useful as a quantitative test. It is usually
applied by means of a special apparatus.

(3) The Fermentation Test constitutes the ultimate test in all cases of doubt, since
sugar is the only known substance fermented by yeast. After seeing that the urine
is acid, fill a test-tube with it, and insert a piece of German yeast ; then invert the
tube over a saucer of water (or mercury) and place them in a warm place. Have a
control tube beside it with normal urine or plain water. If sugar is present, bubbles
of CX)2 ^"^ form and collect at the top of the tube.

This test can also be applied for the qiAantitative estimation of sugar, by Robert's
differential density test. Method. — Have two 12- ounce bottles with a slit cut in the
side of the corks for the gas to escape, and put in each 4 ounces of the urine taken
from a twenty-four hours' sample. Add a piece of German yeast, the size of a walnut,

1 Saundby. Brit, Med, Joum,, April 14, 1900.

388

THE URINE

[}280

to one of them, and set them aside in a slightly warm place for about twenty-four
hours. Then take the specific gravity of the two samples, and the difference between
them gives the measure of the sugar in grains per ounce. The percentage is found by
multiplying this difference by 0*23. Thus, supposing the specific gravity of the two
samples is 1050 and 1005 respectively, there were 45 grains of sugar per ounce, and
45 X 0*23= 10*35 per cent. It is important to wait until all fermentation has ceased,
and to see that no decomposition of urea has taken place in the control bottle.

(4) Picric Acid Test. — Boil a few drops of liq. potasssa with a saturated solution of
picric acid. Add urine and boil ; a dark claret-red colour denotes glucose.

(5) Phenyl-Hydrazine Test. — To about a drachm of urine in a test-tube add 4 g^ins
phenyl-hydrazine hydrochloride and 2 grains of sodium acetate ; boil it in a water-bath
for about half an hour. Allow it to cool by placing the tube in cold water. A yellow
deposit forms, which under the microscope shows fine yellow needle-shaped crystab
in sheaves. This test is the ultimate appeal in cases of doubt.

Fig. 76. — Carwabdine's Sacchakiicster. — A sample of the twenty-four houTB* collection of urine
is used to fill the burette (on right of figure) up to the letter U. Dilute it by adding water to
D U, and mix thoroughly. Fill the measure supplied with the apparatus up to F with
Fetiling's solution, and dilute it by adding water to D F. Pour this diluted Fehling into the
test-tube shown In figure and boil It. While It Is gently boiling add the diluted urine drop
by drop from the burette until all the blue colour has gone from the supernatant fluid.
This may take some little time, as it is necessary after each boiling to wait a minute for the
precipitate to subside a little. For calculation see text.

Lactomria. — Lactose may be present in the urine in considerable quantity in women
who are nursing. Lactose does not answer to the fermentation test, but it reduces
Fehling^s solution. In calculating resiilts remember that 10 parts of lactose have the
same reducing power as 7 parts of glucose.

§ 280. Urea. — ^A healthy male adult, weighing, say, 140 pounds, excretes
about S'5 grains of urea per pound of his body-weight (0-5 gramme per
kilo). We may say, therefore, in round figures, that he excretes daily
about 50 ounces of urine, 500 grains urea (or 10 grains to the ounce), and
that the urine contains about 2'3 per cent, of urea,^ the corresponding
figures on the metrical system being approximately 1,320 c.c, 33 grammes,
and 2-3 grammes per 100 c.c. But these figures vary widely in health, and

^ It is useful to know that the number of grains per oUnce multiplied by 0*23 gives
the percentage*

{ £Sa ] VRBA 389

are much leas (say 300 grains) fot a lighter person taking less food. If tho
kidneys are acting well, the urea output may be increased by an increase
in the nitrogenous food.^ On the other hand, it is considerably diminished
after vomiting or diarrhoea. Particulars on all of these points should bo
investigated and noted ; and a i-pedmen for estimation should be taken
from the unne of twenty-four hours, mixed and measured (§ 275). Finally,
several such observations should be made before concluding that there is
really deficient nitrogenous elimination. There is a deficient elimination
of urea sooner or lat«r in nearly all renal diseases (the accompanying effect
being unemia, § 270), in certain hepatic diseases, in myxcedema, Addison's
disease, and melancholia.

It is now considered that the total quantity of salts in the urine is a
better gauge of the kidney efficiency than the amount of urea (see § 285).

EsTiMinoN OP Ukba. — The speciEo
gravity of the urine gives ug (in the '" *

absence of angarj a very fair idea of
the quantity of urea being excreted ;
indeed, that is the chief reason why we
hftbitaally uao the urinometer (§ 273).
The rapid crystallisation of nitrate of
urea in a test-tube when an equal bulk
of strong nitric acid is added to the
urine and the mixture cooled, suggests
excess ; but fur accurate results it is
necessary to determine tlie total nitrogen
in the nrine (the greater portion of this
being in the form of urea) by volumetric
amJysis. This has been now rendered
available for clinical practice by the
simple apparatus described below.
Albumen, if present, should be separated
by boiling and filtration before beginning
the estimation of urea, and the specimen
of urine should be from the twenty-four
hours' collection mixed.

Doremus' Ureameter (Fig. 77) is so
easily used that it can bo employed for
eetination in one's consulting room.

There are two stages in the process : ^f- T7.-noBE>ctrB' UKKiiiKTiR.

(1) To fill the vertical U tube with a

Bolntion of hypobromite of sodium. This must be freshly prepared immediately
before use, and it is best to keep it in two solutions, potash in one, bromine in
the other, to bo mixed in equal parts just before using. First, holding the tube
vertically, the operator pours the solution into the bulb until it is about half
full, then he inclines the apparatus horizontally so that the fluid passes up into the

• The diumal quantity of urea depends purtly upon the destruction of aitrogeuous
tissues in the body, but chiefiy upon the amount of proteid ingested. The urea depen-
dent upon the latter for its source is usually accompanied by a parallel incraase in the
sodium chloride in the urine, because most proteid foods are rich in sodium chloride.
If, however, the urea, which depends ontissuo-dostructioufoi its source, be increased,
it is urkaccompanied by a parallel increase in the sodium chloride. It is somettmos in
practice a little difficult to determine whotherdoScieney of urea depends upondaflcient
tiHsue-destmctioa or deficient intake of proteids. But if the physiological facts just
named can be relied upon, we have in the estimation of the chlorides an answer to the
question.

390 THE URINE K281-8S8

long or vertical limb of the U tube ; then he restores it to the vertical position, and
repeats the process until the vertical limb is quite full, and the bulb is one-third full or
thereabouts. The tube now contains about 35 c.c. (2) The second stage requires
considerable exactitude. The accuracy of results depends upon the care with which
the pipette is manipulated. Having drawn up the urine very precisely to the 1 o.o.
mark on the pipette, wipe the outside of the pipette rapidly with a towel and introduce
it as shown in the figure just beyond the bend of the U tube. Now comes the most
difficult part of the operation. The rubber top is gently squeezed so as to slowly
and GONTiNUOirsLY press out the urine. Watch the tip of the pipette carefully as the
urine slowly passes out, so as to prevent (i.) the h3rpobromite from coming back into
the pipette ; and (ii.) the air from the pipette going out into the hypobromite. If
either happens, the toBt must be done afresh. The nitrogen, which is rapidly liberated
and collects in the upper end of the vertical limb of the U tube, is the exact measure of
the urea contained in the 1 c.c. of urine used. Set the tube carefully for an hour imtil
the bubbles and heat evolved have subsided, then read off the percentage of urea, or
grains jper ounce, as marked on the side of the vertical limb. The urine must be
examined fresh, and if it contains albumen this must he removed by boiling and filtnUion,
The U tube should be rested on a table or stand. This process estimates the uric
acid and the other products of nitrogenous disintegration as well as the urea, but this
does not invalidate the process for clinical purposes.

§ 281. Uric (i.e., Idthic) Add, either free or combined in the form of
urates, is normally present in a sample from a day's collection to the
extent of 0*04 per cent., or about 8 or 9 grains per diem. According to
Dr. Alexander Haig, it bears in health a fairly constant proportion to the
amount of urea, 1 grain of uric acid per day (per 10 pounds body-weight)
to 35 grains of urea per day (per 10 pounds body- weight) ; the two rising
and falling together. Others {e.g,, Dr. A. P. Luff) say the proportion is
about 1 to 50. Uric acid and urates when in excess are best detected as a
cloudiness or deposit (§§ 288 and 289). Their chemical quantitative
estimation is a matter of some delicacy and difficulty.

The mnrexide chemical test for uric acid, free or in combination as urates, is per-
formed by adding nitric acid to the suspected deposit in a porcelain dish, heating to
dryness, and placing a drop of ammonia on another part of the dish. Where the two
join, a characteristic purple coloration appears. If a drop of caustic potash be placed
on another part of the dish, a blue coloration appears at the junction. To accurately
estimate the quantity of free or combined uric acid in the urine. Gowland Hopkin's
method is usually employed, or that of Haycraft, both of which are laboratory methods,
for which reference should be made to a textbook on chemical pathology.

§ 282. Bile is present in the urine in cases of jaundice, and can be

detected there even before the skin assumes a yellow colour. Both bile

pigments (especially bilirubin) and bile acids are present, the former more

abundantly. An orange-green colour of the urine betrays the presence of

bile if in more than slight amount.

(i.) Omelin^s test for the bile pigments : Add a drop of nitric acid to the urine on a
porcelain slab, and a play of colours will be seen where the fluids meet. (ii. ) MarechaTs
test : Add a few drops of tincture of iodine to the surface of the urine in a test-tube
by means of a pipette, and a green reaction is obtained, (iii.) Pettenkofer's Test for
Bile-acids : Add a solution of cane-sugar to urine ; pour strong H2SO4 down the side
of the glass. At the junction line a cherry-red colour appears. This test is useless
unless the urine contains a considerable quantity of bile. The urine must also be free
from albumen.

§ 283. Blood in the urine (Hsematuria) imparts to the urine a charac-
teristic " smoky " colour, and red blood-cells may be identified under the

K 884» 286 ] BLOOD IN THE URINE 391

microscope (§ 290). A dark colour of different shades may also be imparted
to the urine by Methaemoglobinuria, Haematoporphyrinuria, Alcaptonuria
(all of which are referred to below), and Carbolic Acid. The most delicate
test for haemoglobin, either free or combined in the corpuscles, is the
spectroscopic test (see Fig. 118).

Chemical Test for Blood, — ^Add a few drops of freshly-prepared tr. guaiaci to the
urine and shake, then add excess of ozonio ether. A bine line appears at the junction
of the fluids. The same reaction may be obtained by using filter- or blotting-paper.
Allow a drop of each of the reagents to fall on the paper beside a drop of the urine,
noticing the colour at the junction of the three drops. Fallacies. — Saliva gives the
same reaction, and so do iodides, in patients taking these salts. Pus gives a blue
colour with guaiacum alone. It is very important to have the tincture of guaiaoum
freshly prepared, and to this end it is best to dissolve a little of the resin in rectified
spirit at the time when it is used.

Hasmoglobinaria is always present with hssmaturia, because the corpuscles break
up. Its presence alone is rare, and can only be proved by examining the centrif ugalised
deposit of absolutely fresh urine under the microscope and finding no red cells, although
haemoglobin is present.

Methasmoglobiniiria. — The characteristic smoky colour of the urine in hsematuria
of renal origin depends largely on methiemoglobin, a substance formed from hssmo-
globin by the action of acid urine. It is this pigment also which is found in Paroxysmal
Hsemoglobinuria. It is recognised by the spectroscope.

Ha»matoporphyriiiiiria (Iron-free Hsematin in the Urine). — The urine has a dark
cherry-red colour like port- wine, but gives no guaiacum reaction. It is found after
excessive drugging with sulphonal, and is an indication for at once stopping the drug
and giving alkalies freely. It is known by its spectroscopic bands. If these cannot be
-detected in the urine, the hsematoporphyrin should be extracted by shaking with
acetic ether or amylic alcohol, after adding a few drops of acetic acid ; the extract so
obtained will give the four characteristic bands.^

§ 284. Pui in the urine is best detected by the microscope (§ 290). When in
considerable quantity it may be detected chemically by the addition of an equal
quantity of liq. potassse to the deposit. A ropy gelatinous mass is formed, which
pours from one test-tube to another like a fluid jelly. This test is only applicable
when a fair quantity of pus is present. In small quantities it is best to make a micro-
scopic examination of the deposit for pus cells. When pus comes from the kidney,
the urine is, at any rate when first passed, acid, and the pus is unifortnly disseminated
through the urine, and remains so for some time. When it comes from the bladder,
the urine is alkaline or neutral, and the pus very rapidly collects into a creamy layer
at the bottom of the glass

§ 285 Salti in the Urine. — The total quantity of salts in the urine is of great
importance, for it indicates the functional activity of the kidneys. In this respect it
has usurped the position of the amount of urea, which was thought formerly to give
the best indication. It is estimated by (a) Cryoscopy, (6) Haemolysis (Sir A. E. Wright's
method), (a) Cryoscopy. — ^This method depends upon the principle that the freezing-
point of a solution of salts is proportional to the amount of salt present. If the total
quantity of salts is diminished, the freezing-point is correspondingly higher. The
method is one which requires very careful adjustment, and is therefore a laboratory
procedure, (b) By Hosmclysis. — Sir A. E. Wright has devised a plan whereby the
kidney efficiency is measured by haemolysis. The hsemolytic power of a solution of
salts is proportionate to the quantity of salts present. First we estimate the quantity
of decinormal saline solution necessary to lake a given amount of blood. Secondly,
the quantity of urine required to lake the same amount of blood. From this we know
the amount of salts in the urine, for the amount required contains as much as the

^ Readers who 'are interested in the subject of proteids and pigments in the urine
should consult the writings of Dr. Archibald Garrod {Joum. of Physiology, 1894, xvii.,
p. 349 ; the Lancet, November 10, 1900 ; "iind the Practitioner, March. 1904,

392 THE URINE [§

decinormal saline. Thirdly we may in the same way estimate the proportion of salts
in the patient*s serum. The ratio of the amount of salts in the urine to the amount
in the serum is a measure of the renal adequacy, and is called the " kidney coefficient." ^

Chlorides. — ^The chlorides found in the urine are principally salts of sodium, and
vary in health, according to the food taken, from about 11 to 15 grammes daily. In
disease, the chlorides are increased during convalescence from fevers, during the stage
of absorption of oedema or other forms of serous exudations, and in diabetes insipidus.
They are diminished in acute fevers, especially pneumonia (reappearing at the crisis),
in renal diseases with albuminuria, in gastric disease, such as cancer or dilatation, where
the digestive power is diminished, in anaemic conditions, and, it is said, in melancholia,
idiocy, and dementia.

Test, — Add a few drops of HNO3 to the urine, and an equal bulk of 3 per cent,
solution of AgNOo. A curdy precipitate follows if the chlorides are normal in quantity ;
if the urine only becomes milky, they are diminished.

Quantitative Estimation of Chlorides (Mohr's Method). — After the urine has been
freed from albumen, take 10 o.c. and mix with it 60 c.c. of distilled water ; then add
a pinch of calcium carbonate and 3 drops of a neutral chromate of potassium solution
(1 in 20). The calcium carbonate neutralises any free acid which may be present.
To this a standard solution of silver nitrate is slowly added from a burette, the mixture
being stirred constantly. The white precipitate of chloride of silver separates first,
but the silver nitrate solution must be added drop by drop until the faintest tinge of
pink appears. The pink colour is an indication that chromate of silver is now being
formed, all the chlorides having first united with the silver. Calctdation. — ^Take the
total number of c.c. of silver nitrate used, and deduct 1 c.c. to account for other
substances present in urine which unite with the silver ; then every remaining c.c. of
the solution used represents 10 milligrammes of sodium chloride.

Phosphates. — Phosphates in excess may be attended by a group of somewhat
vague symptoms, which are elsewhere described (§ 314).

Tests, — In an alkaline or neutral urine, phosphates spontaneously form a cloudy
precipitate, which is increased on boiling, but which disappears on acidifying the
urine. If present in a urine that is already alkaline, the deposit is distinguished from
pus by the fact that it is dissolved by acetic acid. The microscope enables us to dis-
ting^uish between pus and phosphates with certainty. This instrument is indispensable
when, as often happens, the two deposits occur together. If the urine be acid, it is
necessary first to add some caustic potash ; and if it be then heated the phosphates
are precipitated.

Sulphates are also normally present in the urine, and there is a total increase with
increase of diet or fever. They exist in two forms : (a) as potassium or sodium sulphate
{inorganic sidphates) ; {b) as combinations of cresol, phenol, indol, skatol, etc. {organic
or ethereal stUpJuUes), A relative increase of the latter group is of considerable import*
ance. It occurs when phenol or allied substances are given as drugs, and as the result
of the action of putrefactive organisms on intestinal contents or abscesses. The exact
determination of the total sulphates or of the proportion of inorganic to organic is too
complicated for ordinary clinical work. To gauge roughly the proportion of organic
sulphates, add to the urine an equal volume of alkaline barium chloride solution.
This precipitates the inorganic sulphates and phosphates. Filter ; add hydrochloric
acid until the filtrate is strongly acid, and heat. The organic sulphates are thus
rendered inorganic, and are precipitated. They should normally form a white cloud
only, and if the precipitate is dense the proportion of organic sulphates is abnormally
high.

§ 286. Proteidi in the Urine. — Besides serum albumen, hsemoglobin, methsemo-
globin, hsematoporphyrin, and mucin and nucleo-albumen, the only proteid which
in the present state of our knowledge has any clinical significance is albumose. For
further details the reader is referred to larger works on the subject.^

Albnmoiaria was formerly known as Peptonuria, but it is now supposed that true
peptones never appear in the urine. Albumosuria occurs where there is great destruc-

^ For further details see the Lancet, October 21, 1905.

^ See an interesting |discussion on this subject at the Roy. Med. and Chir. Soc. of
London, the Lancet, 1900, vol. i.

! 287 ] BARE CONSTITUENTS IN THE URINE 393

tion of white oorposdes, and therefore whenever there is a large collection of pus in
the hody — e.g., in empyema and any abscess formation. It is useful in deciding the
character of an effusion, pleural, peritoneal, or meningeal. Albumosuria also occurs
whenever tissue destruction takes place under the action of micro-organisms. It
appears in the resolution stage of pneumonia, and has been described in connection
with certain liver diseases, such as acute yellow atrophy, with ulceration of the
intestine, with dyspepsia, sometimes when excess of animal food is consumed, and
with some cases of nephritis (together, of course, with albuminuria). It may be the
first sign of that rare disease, myelopathic albumosuria or Kahler's disease^ (§ 449).

Test. — Primary and secondary albumoses are found, the latter being more nearly
related to the peptones — but they have the same clinical significance. (1) Presuming
the urine to be free from ordinary albumen, add HNO3 drop by drop to the urine ; if
a precipitate is formed, which disappears on heating and reappears on cooling, primary
albumoses (? peptones) are present. Both forms of albumose react to the next test.
(2) Acidify the urine strongly with acetic acid, add an equal bulk of saturated salt
solution till a cloud forms ; if it disappears on heating and reappears on cooling it is
due to albumose.

§ 287. Othw Oonitiliients in the urine are acetone, diacetic acid, dioxjrphenyl-acetio
acid, indican.

Acetonuria. — An infinitesimal trace of acetone is always present in the urine, and
this may be increased by a highly albuminous diet. Acetone is also increased in some
febrile states, in cancerous cachexia, and other conditions of inanition. It occurs
principally in diabetes, and it was formerly believed that its presence in definite
quantity in the urine heralded an attack of diabetic coma, but the evidence of this
is not very satisfactory. It is found after the administration of anaesthetics, in delayed
anaesthetic poisoning, in " cyclical vomiting " of childhood, in sudden changes of diet,
and in poisoning by certain drugs, especially by morphia and salicylates,* in all of
which it is associated with diacetic acid, and in diabetes, cyclical vomiting, and delayed
ansBsthetio poisoning with /3-oxy butyric acid also.

Test. — ^Add to a few inches of urine in a test-tube a drop or two of 10 per cent,
solution of sodium nitroprusside, and then pour gently down the side of the tube
strong ammonia solution. A plum-coloured ring forms at the junction of the fluids
on standing.

Diaoetio Add is found in the same conditions as aoetonuria. Its presence is detected
by adding a few drops of a strong solution of ferric chloride, when a Burgundy-red
colour appears.

Aloaptoniiria is a condition where the urine forms a pellicle on the surface and
darkens from the surface downwards on standing exposed to the air, due to the presence
of dioxyphenyl acetic acid. It is an inborn error of metabolism,^ and has no known
clinical significance. Its only importance lies in the fact that it reduces Fehling*s
solution and leads to difficulty in life insurance.

Indicanuria. — Indican (indoxyl sulphate of potassium) is found : (1) where there is
undue intestinal putrefaction ; hence it is present also in cases of gastric disorder with
deficient HCl, HCl being an antiseptic agent. (2) In peritonitis, and some other
diseases where the peristalsis of the small intestines is impeded. Some maintain that
in simple chronic constipation without intestinal obstruction there is no indicanuria,
but von Jaksch and others affirm its presence in constipation and all gastric disorders.
(3) With empyema, putrid bronchitis, etc. (4) Indican is also said to be present, in
small quantity, in decomposing urine.

Test. — ^Add an equal bulk of strong fuming HCl and a few drops of a solution of
potassium permanganate to the urine. This, on standing for a few minutes, produces
a blue colour due to indican, which may be extracted by shaking up with about one-
third its volume of chloroform. Fallacy. — A pink colour develops in the urine of
patients taking iodides.

* Parkes Weber, Med. Chir. Soc. Trans., vol. IxxxvL

* Langmead, Brit. Med, Joum., vol. ii, 1907.
3 A. E. Garrod, Lancet, vol. ii., 1908.

394 THE URINE [K 288-890

§ 288. Qoiidiness of the Urine (naked-eye examination). In healthj
urine there is no deposit, but most of the normal constituents, if in excess,
and some abnormal substances, become evident as a sediment or turbidity.
(1) A bulky pinkish turbidity and deposit in an acid urine, which forms
when the urine cools, indicates the presence of lithates — i.e., urates. It is
the commonest of urinary deposits, and its appearance when the urine gets
cold is typical. (2) Uric Add is evident to the naked eye as a sandy
deposit resembling red cayenne pepper. (3) A white flocculent turbidity
in an alkaline or neutral urine indicates the presence of 'pTiosphates; which
are cleared at once by the addition of a few drops of acetic acid. (4) Cal-
cium oxalate gives a typical " powdered- wig " deposit of fine white points
seen on the surface of a mucous cloud. (5) A fine cloud of vesical mucus
is normally present in the urine, although it is only visible when the
entangled debris and epithelial cells are sufficiently plentiful. (6) Pus
forms a deposit which resembles phosphates to the naked eye, but it is
readily distinguished under the microscope. (7) Urine is sometimes cloudy
from the presence of bacteria, and this cloudiness cannot be cleared by
boiling or the addition of acids.

§ 289. Specimeni of the deposit must always be examined microscopically in cases
of suspected renal disease. The urinary deposit is best examined after the urine has
stood for some hours in a conical glass, or after the specimen has been centrifugalised.^
Take a pipette, close it at the top with the right forefinger, pass it to the bottom of
the glass, allow a small quantity of the sediment to enter, withdraw the pipette, wipe
its exterior with a cloth, place the point on a slide, then surround the pipette with the
palm of the left hand, the warmth of which will cause a drop to exude. Cover the
drop with a cover-glass, and examine first under a J or ^ inch objective, then under a
I or higher. The deposit normally contains foreign substances, such as cotton and
woollen fibres, etc., and a few bladder (and in women nearly always a few vaginal)
epithelial cells, which are recognised by their large and nucleated appearance. Inquiry
should always be made as to the sex of the patient, and in women iif any leucorrhoea is
present. If so, it is very desirable to draw off a specimen of urine by the catheter.

The urinary deposit may contam organised substances (§ 290), or
CRYSTALLINE or Unorganised substances (§ 291).

§ 290. The Organised Ck>ii8titiient8 of the urinary sediment are of far
more serious import than the crystalline substances. They comprise tube-
casts (which are the most important), epithelial cells, pus cells,
BLOOD cells, spermatozoa, and certain rarer stmctures such as microbes,
fat cells, etc.

Tube-caftf and renal Epithelial Celhi are present in all renal maladies
attended by shedding or destruction of the renal epithelium. When tube-
casts are abundant in the urine microscopic examination of the sediment
permits of their ready detection. But if, on the other hand, they are
present only in small numbers, they may be easily overlooked, and this all
the more so when, as in chronic interstitial nephritis and in amyloid disease,

^ For centrifugalisation a special apparatus is necessary, the specimen being placed
in a tube on the edge of a rapidly rotating wheel. It is convenient, (and saves time.

S800]

ORGANISED CONSTITUENTS OF THE URINE

395

the urine is abundant and of low specific gravity, so that any suspended
matter it contains is deposited only slowly and incompletely. Moreover,
these are the exact instances in which the casts are apt to be of the hyaline
variety, and their almost transparent character renders them incon-
spicuous objects in the microscopic field. Hence the search for tube-casts
must be conducted with great care if the risk of a false conclusion is to be
avoided. One of the best methods, after settlement or centrifugalisation
of the deposit, is to examine it with a moderately low power of the micro-
scope, using a narrow diaphragm and shading the light so as to have

Fig. 78.— Renal Tube-casts. — a, epithelial casts ; 6, srantilar cast ; e, hyaline casts ; d, fatty cast;

e, blood casts.

the field only feebly illuminated. Any suspicious-looking object can be
brought into the centre of the field and examined with a stronger lens. In
this way casts may be detected which in a strong light would readily be
missed, and if several slides have been prepared and examined in this
manner the detection of any casts present in the urine is rendered fairly
certain. But the examination should be repeated on several occasions in
any urine containing albumen before a negative conclusion is finaUy
arrived at. The addition of a few drops of methylene blue to the urine
before centrifugalisation is of assistance. The casts do not stain at first,
but in those containing cells the nuclei stain ; and the casts stand out

396

THE URINE

[§«»0

against the pale blue background of the fluid. There is often a special
degree of difficulty in finding casts in alkaline urine, and in decomposing
urine they undergo disintegration.

The clinical importance of tube-casts in the urine is that, with but few
exceptions, they definitely indicate disease of the renal epithelium. Thus,
when found in a urine containing albumen, they add great weight to the
opinion that the albiuninuria is a result of some structural change of the
kidney. Similarly in cases of pyuria and haematuria the detection of
tube-casts not only suggests that the pus and blood are of renal origin, but
also that the kidney is becoming afiected. It must be remembered that
more than one part of the urinary tract may be diseased at one and the

same time. In the urine of patients
who are jaundiced, tube-casts may
often be found without, either at
the time or subsequently, any
evidence of renal disease.

The different kinds of casta (Fig. 78)
are intermingled in most cases. But,
in general terms, epithelial cagis and
blood coats are indicative of the earlier
and more acute stages of parenchy-
matous nephritis. Wtixy casts are not
peculiar to lardaceous kidney, but occur
in other forms of long standing renal
disease. These and fatty casts indicate
that the inflammatory process is passing
to a degenerative stage. OrantUar casts
are more abundant in chronic renal
disease, both tubal and interstitiaL
Hyaline casts, which must not be con-
fused with waxy casts, occur in all
forms of nephritis, both acute and
chronic, and also in health after middle
age. Tube-casts in abundance always
form a serious symptom, but one or
two casts may occur in normal urine.
They are more abundant in the acute
than the chronic forms of renal disease.
Their absence does not count for very
much, as they may be easily missed
or undergo disintegration in the urine.

The continued presence of hjraline and granular casts is more serious than the

temporary appearance of other types.

Renal Epifheliiim (Fig. 79). — The detection of renal epithelium in a
urinary deposit has much the same significance as the presence of tube-
casts. The cells are spherical and rather smaller than bladder or vaginal
epithelium. They may be seen isolated or in small groups. In acute
Bright's disease they may be found in an unaltered condition, but in chronic
disease they become degenerated, and may thus appear crowded with fat
globules. Bladder or Vaginal Epithelium (Fig. 80) is met with as
collections of squamous cells ; transitional, spindle-shaped, and other forms
of epithelium may also be derived from the bladder. Tailed EprrHEUUH

Fig. 79. — Kbnal EpiTHSLruM — a, normal ;
6, fatty ; e, disintegrating.

Fig. 80. — Bladder Epithklial Cells (a) ; and
TAILED EpiTHKUUM (b) from the pelvis of
the kidney.

laM]

ORGAN t8ED CONSTITUENTS OF THE VRtNE

may be derived from the pelvis of the kidney, and the presemje of cells
having this elongated character would greatly aid the diagnosis in a case of
suspected pyelitis. It must be remembered, however, that the male
urethra and the prostate gland yield epithelium practically identical with
the above. A deposit from this source is not uncommon in cases of
chronic prostatitis, the result of a former gonorrhoea.

Pns Corpiiscles, under the microscope, are of globular form with a
diameter about one-third larger than that of a red blood-cell. The
corpuscles are opaque and granular, but when treated with acetic acid they
clear up, and a nucleus is seen (Fig. 81, a and b).

Bed Blood-Corpii8cle8* — ^The detection of red blood-corpuscles in a
urinary deposit is, of course, conclusive evidence of the presence of blood.
In most fresh urines they are readily distinguished, as they retain their

« Crenated red
corpuscles in
concentrated
urine.

a Pus without
reagents.

/ SliriveUed
red cor-
puscles in
catarrhal
cjrstitis.

ft Pus after
addition
of acetic
acid.

d Red corpuscles in \. ^^ c Blood corpuscles

watery urine distended ^*>>^^ ^.^^ (normal appearance) in

by imbibition. — -J_— — — fresh urine.

Fig. 81. — ^Various appearances of kbp blood oorpusolbs and pus cells. — In very pale, watery
urine the red corpuscles may be so pale as to escape detection {d). They may then be revealed
by adding a solution of iodine in potassium iodide.

bi-concave form and the outline shows a double contour (Fig. 81, c). But
sometimes the corpuscles become much changed. Thus in a very dilute
urine they are apt to become distended by imbibition, and then are seen
as circles having sharp delicate outlines ((Q. In other instances they
become crenate, shrunken, and deformed {e and/).

Spermatosoa may occasionally be found in the urine. Each has a minute oval or
pear-shaped head, from the larger extremity of which there passes a long and delicate
tail. The total measurement of the spermatozoon is about ^^ inch in length.

Kiorobei. — Numerous microbes are found in the urine, especially when decom<
position has occurred either within the bladder or subsequently. The most constant
are the BacUlua urem, Vibriones, and the Hay hac%Uu8 (bacillus subtilis), which have
no special clinical significance apart from putrefactive changes. Oonococcus is found
in cases of gonorrhoea, and the typhoid bacUlus may be abundant in oases of enteric
fever.

398 THE VRINE [§201

The TuBEBCLB Bacillus may be found in tuberouloos disease of ihe bladder or
pelvis of the kidney, and is therefore a sign of great value. In appearance under the
microscope it resembles the smegma bacillus. Its special staining reaction will be
given in Chapter XX., § 627. It is difficult to find in the urine early in the disease,
and in obscure cases the experimental test upon guinea-pigs should be employed,
the urine for inoculation being collected through a sterilised catheter into a sterilised
bottle.

The B. CoLi Communis is sometimes found in the urine in pure culture, and may
produce an Ascending Pyelo-nephritis (§ 305). The bacilli of the urine and their
clinical and pathological relations would well repay study.

§ 291. Gnrstalline and Inorganic Deposits in a urinaiy deposit are usually
of less serious import than the organised substances above noted.

In ACID URINES we meet chiefly with urates, uric acid, oxalates, and —
among the rarer substances — stellar phosphates, cystin, xanthin, hippuric
acid, tyrosin, and leucin.

Fig. 82. — Urates. — a. Amorphous urates of sodium and potassium ; fr, " Hedgehog *' cry'stals of

sodium urate ; e. Ammonium urate.

In neutral or alkaline urines we meet chiefly with triple phosphates
(occasionally urate of ammonium and calcium carbonate).

Amorphous deposits of urate of potash or ammonia, and phosphates
and carbonates of the alkaline earths may be met with in urines of either

REACTION.

1. Urates (t.e., Lithates), chiefly of sodium, potassium, or ammonium, when in
excess are deposited as an amorphous brick-coloured deposit after the urine (warm
when first passed) has become cold. A deposit having these characters, and dis-
appearing when heated in a test-tube, is sufficiently characteristic for the detection of
lithates. The deposit is dissolved on the addition of caustic potash ; a test which also
distinguishes urates from phosphates. Urates of Soda and Potash, under the micro-
scope, appear as amorphous orange or pale hroum granules (Fig. 82, a). Urate of Soda
may occasionally appear as '* hedgehog '* crystals, globular masses covered with
spikes (Fig. 82, 6). Urate of Ammonium occurs as globular masses, sometimes spiked.

sm]

CRYSTALLINE AND INOBOANIO DEPOSITS

300

very like sodium urate, but known from such by being found in alkaline urines
(together with phosphates) and by being dissolved by acids (Fig. 82, c).

Clinically, urates and uric acid are important only when they occur cangtanUy, in
fresh urine, or in urine that has stood a few hours only. Gouty and other symptoms
are apt to arise in such cases (see LiTHiBMiA, § 240), and calculus might be expected
to form in the bladder or kidney. An occasional deposit of urates, or a deposit
occurring in urine that has stood over six hours, is of but little importance. In all
concentrated urines, on cooling, large deposits of urates normally occur. The patient
may think the deposit is due to blood.

2. Frbe Uric Actd is deposited when the urine is very acid or poor in salts and in
pigment, and is therefore found chiefly in dilute pale urines with deficiency of salts.
The red deposit of uric acid closely resembles cayenne pepper to the naked eye. It may
be detected in the urinary deposit under the microscope by the colour and shape of the
crystals. It occurs in the form of red-brown crystals (the only coloured crystals com-
monly found in the urine), mostly lozenge-shaped (Fig. 83). Uric acid assumes many
different shapes, owing to the presence of the colloid substances in the urine, but they
are all derivatives from the rhombic prism or
parallelogram, in which form uric acid crystallises
from pure water. The more pigment, mucus,
and other colloids there are in the urine the more
spherical do the crystals become. Some of these
are shown in the accompanying illustration, and
the gradual transition from rhombic prism to dumb-
bell and other spherical fopms will be seen by
following the crystals from left to right. ThUi
deposit is soluble in caustic potash, insoluble in
dilute acetic acid, the converse of phosphates.

In health uric acid is increased with a highly
nitrogenous diet, after much exercise, after meals,
and during the ** alkaline tide '' of the morning.
It is also increased in most fevers, in splenic
diseases, pernicious ansemia, in some cases of
dyspepsia, during and after an acute attack of
gout, and during an attack of acute rheumatism.
It is diminished in chronic gout, especially just
before the acute exacerbations ; in chronic Bright*s
disease ; in chlorosis and other chronic diseases.

3. Phosphates occur as a white deposit or floccu-
lent turbidity in feebly acid, neutral, or alkaline
urine, in three different forms, which in order of
frequency are : {\) Amorphous phosphcUes of calcium

Fig. 83. — Uric acid crystals (red-
brown). — ^The two top rows show,
from left to right, the evoIaUon
in a coll(Hd medium of the
" lozenge-shaped " crystal from
the primary rhombic prism. In
the lower right-hand comer is
the " domb-bell " form occasion*
ally met with.

form the thick white deposit that is apt to be
mistaken for pus, but which is more readily shaken up in the urine. These and all
other phosphates are soluble in acetic acid, and precipitated by ammonia. The latter
test decomposes neutral phosphates. (2) Triple phosphate of ammonium and mag-
nesium (Fig. 84), is found in urine which has undergone alkaline fermentation. The
crystals are large colourless three-sided prisms like *' house-tops," occurring singly, or
as snow-flakes or other irregidar forms. In markedly ammoniacal urine " feathery
phosphates '' are found. (3) Basic magnesium phosphate occurs in large rhombic
plates, not grouped, but scattered (Fig. 85). (4) Neutral or dicalcium phosphate occurs
in neutral or alkaline urines as clear, refractile, pointed or wedge-shaped prisms
arranged in stellate groups — '' stellar phosphates " (Fig. 86). The constant presence of
phosphatic deposits may be associated with symptoms (§ 314), or suggest the presence
of a stone. Monocalcium phosphate occurs chiefly in acid urines.

4. Oxalates are chiefly met with as oxalate of calcium. This occurs as a scanty
crystalline deposit of colourless transparent ootohedra, appearing, under the micro-
scope, like tiny envelopes, hence the name "" envelope crystals '' (Fig. 87). They
sometimes rest like fine powder above a cloud of mucus, and have been described
therefore as the " powdered wig *' deposit. They are soluble in hydrochloric acid.

400

THE URINE

[§m

insoluble in acetic acid or caustic potash. Oxalate of calcium may also occasionally
appear as dumb-bell shaped crystals. These crystals are much clearer and more highly
refractile than any other, and atypical forms may be recognised by this feature. The
presence of crystals of oxalate of calcium is indicative of an excess (Oxalubia,
§ 314) ; their presence may also suggest the nature of a calculus. They are said to be
abundant in the early stage of chronic pancreatitis.

Fig. 86. — Neutral or " stellar "

PH08PHATB.

Fig. 84.— Triple phosphate—" house-top *' and
" feathery '* crjrBtals.

Fig. 85. — ^Basio MAaNEsnrx

PHOSPHATE.

^^^

Fig. 87.— Caloium oxalate—
" envelope *' and *' domb-
bell '* crystals.

•i

Fig. 88.— Calcium
Carbonate.

5. Calcium Carbonate is a rare deposit, consisting of tiny spheres and dumb-bells»
or of amorphous granules, effervescing and dissolving in acetic acid (Fig. 88). The
Carhonates of the Alkaline Earths are very occasionally found as tiny amorphous
granules or concretions. Calcium sulphate and carbonate may take part in the

formation of vesical calculi, especially in the aged, but
otherwise they are of no clinical significance. Their presence
only points to the existence of a calculus, and indicates
its composition.

When a patient is taking crystalline drugs, such as acetate
of potash and phosphate of soda, or even liquor ammonise,
various crystals which have no pathological significance
sometimes appear in the urine. Moreover, after a reagent
has been added to urine (e.^., Esbach^s solution for

the estimation of albumen), and it has been set aside, crystals may also appear

which have no clinical value.

6. Certain rare and leas important deposits, which occur chiefly in acid urines, are
as follows : Hippuric Acid is an antecedent of uric acid in the nitrogenous metamor-
phoses of the tissues. It occurs as four-sided prisms, either scattered or in groups.
It is present after the ingestion of benzoic acid in large doses, cranberries, and other
fruits. Calcium Sulphate occurs either as amorphous granules, or, very rarely, as
long colourless needles or elongated tables with truncated ends. It is detected by
being insoluble in ammonia and acids. Leucin occurs as laminated spheroids, and
Tyrosin as bundles of acicular crystals (Fig.;72 ). Both occur in the urine in phosphorus
poisoning and acute yellow atrophy of the liver. Chdesterin (Fig. 71) is only occasion-
ally found among urinary deposits. It forms laminated plates with longitudinal strise,
and a notch at one end. Cysiin occurs as hexagonal plates soluble in ammonia
(Fig. 72, §241).

1292] PHYSICAL EXAMINATION OF THE KIDNEYS 401

PHYSICAL EXAMINATION OF THE KIDNEYS.

§ 292. A dull " sickening pain " is usually felt on firmly compressing
the kidney with both hands, but there is no tenderness in a healthy organ.
Tenderness may be elicited in cases of calculous and other forms of
pyelitis, perinephric inflammation, abscess, or tumour of the organ.
Kidney tumours tend to grow forwards, where there is least resistance,
pushing the resonant colon in front of them. When, therefore, the pal-
pating hand encounters resistance and swelling in the lumbar region
posteriorly, it is probably due to a peri- or extra-renal, rather than to a
renal condition (see Fig. 37, § 75). The diagnosis of renal swellings from
other abdominal tumours has been given in § 188. An extra-renal tumour
may press the kidney backwards, so that the apex of the tumour may be
due to the displaced kidney.

In the majority of renal disorders the physical examination of the kidney is of
secondary importance to the examination of the urine. The kidneys are situated on
either side of the spine, about 3 inches from the middle line ; the right is slightly lower
than the left, owing to the position of the Uver just above it. The upper end of the
right kidney reaches to the lower edge of the eleventh rib ; the left kidney reaches as
high as the upper edge of the eleventh rib. The kidneys lie partly in the hypo-
chondriac and partly in the lumbar regions, and are therefore much higher than is
commonly supposed, with reference to the anterior abdominal wall. The lower end
of the right kidney is 1 inch and that of the left kidney 1} inches above the level of the
umbilicus.

Palpation. — Even in normal conditions the lower border of the right kidney may
be palpable in thin people. In those whose abdominal walls are lax — ^in women who
have borne children, for instance — it is surprising how frequently the right kidney
can be palpated. The patient should lie on the back, with the abdominal muscles
relaxed. The physician, standing on the right of the patient, should place his left
hand beneath the patient's back, close under the ribs, just external to the quadratus
lumborum. The right hand is laid flat over the anterior surface of the abdomen, in the
mid-clavicular line, with the fingers pointing upwards, just below the liver. I^essure
backwards, as if to meet the left hand, is made by the right hand. The patient should
then be asked to draw a deep breath, and as he does so the rounded lower edge of the
kidney is felt to slip between the opposing hands. When the ligaments of the kidney
are relaxed — mowMe kidney — the fingers of the right hand may be able to palpate
the upper border of the organ, and to retain it during expiration. A kidney is said
to be ** floating *' when it can not only be readily palpated, but can be pushed below
the umbilicus or freely moved about in the abdominal cavity.

Percussion does not enable us to define the margins of the kidney, for the organ is
too deeply seated. The feature of primary importance in this connection is its relation
to the colon, which, as just mentioned, is pushed forward by enlargements or tumours
of the kidney. Consequently the anterior surface of such growths is always resonant,
there being dulness at the side which is continuous with that at the back ; whereas
with enlargements of the spleen or gall-bladder there is dulness anteriorly and
resonance at the side.

Other methods of examination of the kidneys are now open to us. In cases of
doubtful renal calculus a radiogram will usually settle the diagnosis. Examination
of the ureteral orifices by means of a cystoscope may demonstrate which kidney is
affected, for the normal flow of urine may be absent or visibly altered, and the orifice
itself may be the seat of infiltration or ulceration. The previous administration of
methylene blue or other harmless pigment may make the differences of the flow from
the orifices more obvious (chiomo-cystoscopy). The ureters may be catheterised*
and a specimen of urine obtained in this way from each kidney. The condition of the
bladder is also revealed by the cystoscope. Lastly, pyelography has proved useful to

402 THE URINE [§§298.294

determino the condition of the ureters and pelvis of the kidney. A 10 per cent, solution
of oollargol is injected through a ureteral catheter, and on X-ray examination an
opaque shadow is thrown where the solution has penetrated.

PART C, URINARY DISORDERS, THEIR DIAGNOSIS. PROGNOSIS,

AND TREATMENT,

§ 293. Boutine Procedure and Classiflcation. — First, having ascertained
that the patient's Leading Symptom refers to the urinary apparatus ; and,
secondly^ the data of his illness, particularly as to whether it is of an
Acute or Chronic nature ; we proceed, thirdly^ to examine the urine.
The Boutine Examination of the Urine in everyday practice consists of
Inspection, Reaction, Specific Gravity, Tests for Albumen and for Sugar.
The subsequent and more detailed examination depends upon circum-
stances. As above stated, the examination of the urine stands in relation
to renal disease, as the local signs do to diseases of other organs. There
are very few diseases, certainly no common disorders of the kidneys, which
are not attended by some change in the urine. On the other band, the
LOCAL examination of the kidney, by palpation and percussion (§ 292), is
difficult and relatively much less certain and instructive. On this account
it comes last in our scheme of examination, but it should never be omitted
in any case which is at all obscure.

ClassiflcatioiL — We will deal with urinary disorders under their respective
cardinal symptoms as follows :

Albuminuria
Hsematuria
Pyuria - . -
Alterations in the specific gravity
Polyuria - - - -

Glycosuria ...

Retention of urine
Suppression of urine
Incontinence of urine
Presence of various deposits
Renal enlargements

§ 294
§ 300
§ 303
§ 306
§ 307
§ 308
§ 311
§312
§ 313
§ 314
§ 316

§ 294. Albuminuria. — ^The numerous morbid conditions which may give
rise to albuminuria may be divided into three great anatomical (and clinical)
groups : A. Acute Inftammation of the Epithelium (Acute Nephritis or
Acute Bright's Disease) ; B. Chronic Inflammations and Degenerations ;
C. Renal Congestions, either active or passive, which include many cases of
albuminuria, independent of structural disease of the kidney.

If, therefore, the illness came on recently, and is of an Acute character,
turn first to § 295 (Acute Nephritis), and then to § 299 (Renal Congestions).

If, on the other hand, the illness is of some duration, and evidently
of a Chronic kind, turn first to § 296 (Chronic Tubal Nephritis), and then
the succeeding sections.

When the albumen is in small quantity, and there is also blood or pus
in the urine, turn to § 300 (Haematuria), or § 303 (Pyuria), respectively.

§ 295 ] ACUTE NEPHRITIS 403

The iUness came on recently ^ and is acute ; the urine is diminished, and
contains a considerable quantity of albumen and tube-casts \ it is or has
been " smoky " from the presence of blood ; anasarca is present ; and there
is a tendency to urcemia. The disease is Acute Nephritis

§ 295. Acute Nephritis (Acute Bright's Disease). — In this disease the
inflammation begins and predominates in the epithelium or parenchyma
of the organ. The condition usually lasts from five to six weeks, and may
terminate in recovery or pass on to a chronic condition.

Symptoms. — (1) The albumen is often in considerable quantity, and the
urine may even *' go solid " on boiling. (2) The other characters of the
urine are : (i.) It is scanty, sometimes only 10 or 20 ounces a day, or less.
Consequently, the specific gravity is high, although the diurnal quantity
of urea is diminished, (ii.) It varies from a turbid or " smoky " to a dark
brown hue from the presence of blood, (iii.) Epithelial, hyaline, and blood
casts, free renal epithelium, and red blood-corpuscles are present.

(3) Dropsy is general from the commencement, although it is first noticed
in the face in the loose areolar tissue below the eyes and in the genitals.
There may also be collections of dropsical fluid in the serous cavities.

(4) There is a waxy pallor of the skin. (5) A degree of malaise, with dis-
comfort and even pain in the loins, may be present, but there is only a
slight elevation of temperature for about four or ^ve days. (6) UrsBmic
symptoms may come on early — e.g,, (i.) occasional vomiting, (ii.) head-
ache, (iii.) drowsiness. (7) If the disease goes on for any time the blood-
pressure becomes high, and the second aortic sound is accentuated.

Causes. — Acute nephritis is only rarely a primary malady. (1) Ninety
per cent, of the cases supervene on an acute specific fever, and by far the
most conmion of these is scarlet fever. (2) Chill, especially a sudden chill
when the skin is perspiring. (3) Traumatism — i.e., a blow on the kidney
is an occasional cause. (4) The persistent use of certain drugs, such as
cantharides and turpentine. (5) Inflammation secondary to disease of the
urinary tract below the kidney (see Ascending Pyelo-nephritis). (6) Preg-
nancy is a marked predisposing, and sometimes exciting, cause.

Prognosis. — Acute Nephritis may terminate in (1) complete recovery in
a few weeks, the usual result when the treatment and hygienic surroundings
are good. (2) Partial recovery. If the disease lasts longer than three
months, it usually develops into the condition known as large white kidney
(Chronic Parenchjrmatous Nephritis, § 296). (3) Death may occur from
uraemia, from dropsy into the serous cavities, or from other complications.
The chief complications are : (a) Uraemia ; (6) inflammations of the serous
membranes, such as pleurisy, pericarditis, or peritonitis, which are usually
latent — i.e., attended by little or no pain ; and (c) inflammations of the
mucous membranes, such as bronchitis, gastritis, enteritis (causing diar-
rhoea) ; {d) oedema of the lungs or of the glottis ; (e) cardiac dilatation and
failure ; (/) erysipelas, cellulitis, and various other skin diseases are very
prone to attack patients with acute nephritis.
, The prognosis, therefore, of acute nephritis is grave in proportion to

404 THE URINE [S896

(i.) the diminution of urine ; (ii.) the development of ursBmic symptoms ;
(iii.) the amount of dropsy present ; and (iv.) the nature and severity of
the complications.

Treatment, — The indications are to relieve the kidney by giving only
bland non-irritating food — e,g., milk ; to increase the action of the skin
and bowels; and to lessen local congestion. (1) To obviate the great
liability there is to chill, the patient should be kept in bed ; and for the
same reason all cases of scarlet fever should be kept in bed during
convalescence, because they are so apt to develop this disease. (2) Diapho-
retics, such as liquor ammonias acetatis, antimonium tartrate, or pilo-
carpine nitrate (gr. J to J subcutaneously), warm baths, wet packs, and
hot-air baths. This treatment may be applied by means of a wicker cage
placed upon the bed, and connected with a spirit-lamp through an iron
chimney at the foot. (3) Purgatives, such as pulv. jalapsB co. (30 grs. to
3i.), are indicated. Saline purgatives are especially useful when there is
much dropsy. (4) There is some difference of opinion about diuretics ;
some say that they irritate the kidney, others that they relieve the
symptoms, and especially the dropsy. It is agreed that during the acute
stage copious libations of water, but no other diuretic, should be used.
Saline diuretics employed are potassium bicarbonate, citrate, acetate, and
bitartrate. In mild cases the Imperial drink may be taken freely — 3iss.
cream of tartar dissohed in a pint of boiling water, flavoured with sugar
and lemon- peel. Scoparium and digitalis are given with caution if the
heart is feeble. (5) Local depletion by wet or dry cupping is especially
indicated when the urine contains much blood. Counter-irritation over
the kidneys, with poultices or leeches, has a similar effect. (6) During
convalescence tonics, especially iron, must be given. An admirable pre-
scription is liq. ferri perchloridi, n\xv. ; liq. ammoniee acetatis, 3i. ; acid,
acetici, ll|^v. (to prevent decomposition). Animal food should be forbidden
so long as albuminuria continues. In the treatment of renal disease three
drugs are contra-indicated — opium, cantharides, and turpentine. Mercury
is generally added to these, but I hdve never seen any harm arise from its
administration. Foi the treatment of Urcemia, see § 297.

Chronic Albuminuria. — There are three anatomical varieties of chronic
renal disease attended with more or less albuminuria, which, when occurring
in their typical forms, present well-marked clinical distinctions, as shown
in a tabular form below. In Chronic Tubal Nephritis (including large
white kidney), the renal epithelium is primarily and throughout the
disease chiefly involved. In Chronic Interstitial Nephritis (Grouty Kidney)
the interstitial tissue shows evidence of increase, and throughout the disease
this is the most marked change ; the arteries also, however, show hyper-
plasia of their middle coat.i This arterial change also occurs throughout
the body, and is attended by a corresponding hypertrophy of the left
ventricle. In the Amyloid (or Waxy) Kidney the vessels are primarily
involved, the lardaceous degeneration beginning in the middle coat.

^ C/. Introduction to this chapter.

296]

CHRONIC TUBAL NEPHRITIS

405

Pathologists make many subdivisions, but these represent the three
clinically recognisable groups of chronic renal changes attended by
albuminuria.

Table XX. — Dr. Murchison's Table of Chronic Albuminuria.

' Chronic Tabal
Nephritis.

Quantity of
AlbufMn.

Tendency to
Uramia.

Moderate.

Great.

Quantity of Urine.

Diminished or
normal.

Tendency to
Dropsy.

Large.
Very small.

Great.

Chrooio Inter-
Btitial Nephritis.

Increased.

•

Very slight.

Waxy Kidney.

Very great.

SUght.

Greatly increased.

Slight.

If the albumen is oonsidsbabls, turn to Chronio Tubal Nephritis, Amyloid Kidney,
or Chronio Renal Congestions. If there is only a tbaob of albumen, and the urinary
signs appear to be slight in proportion to the debility and other symptoms, turn to
Chronic Interstitial Nephritis, § 297.

The illness is chronio^ and the general symptoms of renal disease pro-
nounced ; generalised dropsy is marked ; the urine is scarUy, and albumen
and CASTS are abundant. The disease is Chronic Parenchymatous
Nephritis.

§ 296. Chronio Tubal Nephritis (synonyms : Large White or Pale Kidney,
Chronic Parenchymatous Nephritis, Chronic Desquamative or Catarrhal
Nephritis, Fatty Kidney) may follow on acute nephritis, or may develop
insidiously. In the later stages the connective tissue is increased, and if
the patient lives long enough the kidney becomes a Contracted Fatty
Kidney, or Small White Kidney.

Symptoms. — (1) The albuminuria is considerable, J to J of the volume
of the urine ; (2) the other characters of the urine are : (i.) the diurnal
quantity is slightly diminished at first, but towards the end, when the
kidney contracts, the quantity may be greater than normal; (ii.) the
specific gravity is not much altered in the early stages, but the urea is
deficient throughout ; (iii.) it is turbid, often with lithates ; and recurrent
hematuria may occur, especially if the condition has followed acute
nephritis; (iv.) all forms of casts are met with (§ 290). (3) There is
generalised dropsy, but most marked in the face. It may disappear
towards the end, when the diurnal quantity of urine increases. (4) There
are pallor, emaciation, weakness, and digestive disorder ; and (5) cardio-
vascular symptoms (§ 267) ensue.

Etiology. — (1) Chronic tubal nephritis frequently follows acute nephritis,
or (2) it may result from prolonged mechanical congestion of the kidney
(as in cardiac disease). (3) Sometimes it comes on insidiously, without
apparent cause. (4) Alcohol in excess predisposes. (5) It is most often
seen in males of middle age.

406 THE VRINE [ § 297

Diagnosis, — When the insidious form occurs in young women it is often
mistaken for chlorosis; in all cases of ansBmia, examine the urine for
albumen. In the later stages it may be mistaken for chronic interstitial
nephritis ; but in that disease the patient is usually older, and see Table XX.
In certain cases which present both renal and cardiac symptoms, it may be
very difficult to say which condition is the primary one. In such cases it is
important to note the following points : (i.) If there is a history of rheumatic
fever and previous attacks of dropsy, it is probable that the cardiac con-
dition is primary, (ii.) If other than mitral systolic murmurs are present it
points to cardiac disease ; a mitral regurgitation murmur alone might be
due to the cardiac failure following renal disease, (iii.) The urine^ when
there is any difficulty in diagnosis, is in both cases scanty and albuminous.
Many tube-casts point to renal disease ; the rapid clearing up of the dropsy
and improvement of the urine after a short period of rest in bed points
to heart disease, (iv.) A hard pulse favours kidney disease, but an
irregular soft pulse is found with cardiac failure secondary both to renal
and to cardiac disease.

Prognosis, — When once established the disease can never be cured, and
even with careful diet and treatment the patient rarely lives more than a
few (two to five) years. Death occurs as a consequence of dropsy, uraemia,
or complications (as in acute nephritis). The prognosis is grave in pro-
portion to (1) the amoimt of dropsy and albuminuria ; (2) the diminution
of urine ; and (3) the presence of ursemic symptoms. If the patient survive
for several years, the prognosis improves ; because, when the stage of
contraction sets in life may, with care, be somewhat prolonged.

The Treatment is much the same as that of acute nephritis (q.v,) ; but
two points demand constant attention : (1) The avoidance of chill, by the
wearing of flannel and resort to equable climates ; (2) careful dieting, with
the object of reducing the nitrogenous intake to a minimum. The latter
is best accomplished by making the patient live entirely on milk, 2 to 4
pints per diem, and as much fluid as he can drink. If meat be taken, it
should not exceed 2 or 3 oimces once a day. Stimulants, meat extracts,
and animal soups should be avoided, unless evidences of a fatty heart are
present. Purgatives should be administered so that the bowels act twice
a day. Tonics, and especially iron, are the best drugs. The best tonic is
that prescribed for convalescent acute nephritis {q,v,) ; it may be combined
with a diuretic. Edebohls has obtained some good results from surgical
treatment, decapsulation of the kidney.

The patient complains of lassitude, and other symptoms of incipient
URiEMiA mentioned in § 270. There are only traces op albumen, the
diurnal quantity of urine is increased, dropsy is absent. The disease is
probably Chronic Interstitial Nephritis.

§ 297. Chronic Interstitial N^hritis .(synonyms : Ck)ntracted, Granular,
or (Jouty Eddney ; Cirrhotic Eadney ; Renal Fibrosis ; Small Red Kidney ;
Chronic Non-Desquamative Nephritis). — It is accompanied by widespread

1 261 ] CHRONIC INTERSflftAL NEPMBITIS 407

cardio-vascular changes, as mentioned in the introduotion to this chapter,
consequent on recurrent high blood-pressure.

Symptoms, — (1) The albuminuria in this disease is small in amount, and
many samples of the urine may be examined without finding any. In
cold weather, however, when there is deficient sldn action, there is gener-
ally a trace, especially after a chill or any cause which produces renal
congestion. The other characters of the urine are : (ii.) The diurnal
quantity is greatly increased (maybe to 100 ounces). The patient often
consults us because he has to get up at night several times to pass water,
(iii.) The specific gravity is very low (1005 to 1012), owing partly to the
deficiency in urea, but chiefly to the increased quantity of urine. The
deficiency in total urea is not very great, and may not be sufficient to
suggest the onset of urasmia ; the total amount of salts in the urine is
diminished, and affords a more reliable indication (see § 285). (iv.) The
urine is clear, pale, and contains but few casts, and these are chiefly hyaline
or granular (Fig. 78). (2) Dropsy is usually absent. If dropsy occur it is
due to (i.) secondary cardiac failure, or (ii.) the supervention of acute
nephritis. Sir George Johnson foimd a history of dropsy in only fourteen
out of thirty-three cases. (3) The patient may look robust, but sometimes
he has a greyish pallor. (4) The pulse indicates persistent high blood-
pressure, and is often associated with hypertrophy of the left ventricle, an
accentuated aortic second sound, sometimes with a systolic apical murmur,
and always sooner or later with a thickened condition of all the arteries.
Later the heart may dilate, with consequent dropsy and albuminuria, and
it may be hard to diagnose whether the kidney or the heart condition is
primary or secondary (§ 296, Diagnosis), (5) There is throughout a con-
dition of chronic or incipient uraemia (§ 270), due to the deficient nitro-
genous metamorphosis in the body, and the retention in the blood and
tissues of the antecedents of urea, owing to deficient renal function. These
symptoms are indefinite, but in order of importance they are : (i.) Insomnia
and headache, symptoms which, occurring in the aged, should always lead
us to suspect granular kidney ; (ii.) gradual impairment of the mental and
bodily vigour ; (iii.) tremors and twitching of the muscles ; (iv.) digestive
disorders ; (v.) dyspnoea, often paroxysmal.

Course and Complications, — ^Apart from the existence of slight and inter-
mittent albuminuria and persistent high blood-pressure, non-urinary
symptoms are the earliest, and often for prolonged periods the only evi-
dences of this disease. In many cases the high pressure first reveals the
disease to the physician ; in other cases it is the ophthalmoscopic changes
(Renal Retinitis, § 267), changes which may or may not be attended by
failure of vision. Apart from the progressive enfeeblement, the disease
generally first manifests itself by the occurrence of one of its numerous
complications. The most frequent and most serious of these is cerebral
hcBmorrhage, resulting from the prolonged high blood-pressure and conse-
quent arterial degeneration. Hcemorrhages of various kinds may occur in
other directions, such as epistaxis, or melsana. Epistaxis constitutes a

408 THE U^INS [{297

kind of safety-valve, relieving the vascular system from more serious
internal haemorrhages, consequently it should not be checked. The
mucous membranes are often affected, and intractable bronchitis or gastro-
enteritis in an elderly person may be the condition which brings the
patient under our notice ; the serous membranes less often, though a latent
form of pleurisy or pericarditis is not uncommon. Skin diseases are often
very troublesome. The earliest symptom noticed in many cases is the
itching of the skin : Urticaria, ec2ema, erythematous, desquamative, and
hsemorrhagic eruptions are apt to occur. The patient is liable, on exposure
to cold, to attacks of congestion of the kidney, when the albuminuria and
all the other symptoms are aggravated.

The Diagnosis from other forms of chronic renal disease is given in
Table XX., p. 405. However, the diagnosis of this form of chronic renal
disease from the other conditions which give rise to lassitude and dbbiuty
is often a question of much greater difficulty (§ 401). In the diagnosis
from cardiac failure due to cardiac valvular disease the hbtory is
important, and cf. p. 406.

Etiology, — (i.) I have assisted at an autopsy in a well-marked case of
granular kidney in a child of nine ;^ but the disease almost invariably
occurs in persons of middle age or advanced life. Out of 376 cases admitted
into the Paddington Infirmary 317 were over forty years of age, 251 were
over fifty, and 203 over sixty, (ii.) Gout and a gouty habit of body are the
most important causal factors. In many cases there is a long history of
persistent lithuria, and in a large proportion of cases of granular kidney
the joints and ears show evidences of gouty deposit; hence the name
" gouty kidney." (iii.) An indolent life, and (iv.) chronic lead foisoning
are undoubtedly causes, not only of gout, but of granular kidney,
(v.) Various other forms of toxcemia which produce recurrent or constant high
blood-pressure (q.v.) may also be followed by chronic interstitial nephritis.
Many of the symptoms usually attributed to chronic interstitial nephritis
(renal fibrosis) are really those of high blood-pressure, and in the author's
opinion 2 renal fibrosis is an accidental occurrence in certain cases of
toxaemic high blood-pressure — not in all.

Prognosis, — The course of the disease, as already mentioned, is prolonged.
With care and attention to diet the patient may live for five, ten, or more
years, but the disease can never be cured. The amount of albumen is no
criterion as regards prognosis in chronic interstitial, as it is in chronic
parenchymatous, nephritis. The prognosis is grave in proportion (1) to
the duration of the disease ; (2) to the evidences of urcemia present and their
degree ; (3) the degree of cardiac failure ; and (4) the presence and severity
of the complications {vide supra). Life is frequently terminated by cerebral
heBmorrhage or some other complication ; a large number of these cases die
of acute urfiemia (§ 270), as the records of the Paddington Infirmary show.

^ In childhood the leading symptoms are general pigmentation, polyuria, and
headache. The first is explained oy the possible invasion of the adrenals. The head-
ache is often worse on rising in the morning — i.e., like a high tension headache.

2 *' On Senile Epilepsy," the Lancet, July, 1909 ; and elsewhere. See also p. 378.

§298] CHRONIC INTERSTITIAL NEPHRITIS 409

Older authors desoribed this as death by " serous apoplexy," thinking that
the serum which replaced the atrophy of the brain was the cause of
pressure upon that organ. Death may be due to cardiac failure.

Treatment, — ^Diet is of chief importance. The amount of purin con-
taining food should be reduced to a minimum, and alcohol forbidden.
All chances of chill should be avoided by clothing in flannel, and living
in equable climates ; and the action of the skin should be maintained. The
arterial pressure should be slowly reduced (§ 61) ; this takes the strain ofE
the heart, and will cure symptoms such as headache and insomnia due to
high pressure. Purgatives, such as mistura alba, will do a great deal for
this, at the same time enabling the bowels to drain ofE the poisonous sub*
stances which ought to be eliminated by the kidneys. Tonics are useful,
such as nux vomica, and digitalis for heart failure. The action of the
latter must be carefully watched (special heed being given to the pulse),
lest it produce apoplexy or other haemorrhages. Iron is not of much use,
and may do harm by leading to constipation. Symptomatic Treatment. —
(i.) Liquor trinitrini, n\^i., b.d. will cure headache when due to high tension,
and calomel, gr. ^, once or twice daily is also good; (ii.) Potassium iodide
relieves tension, and may prevent further arterio-sclerosis. (iii.) For the
attacks of '' renal asthma '' amyl nitrite, chloroform, or venesection may
be necessary, (iv.) For restlessness, chloral and bromides are useful.

The treatment very often resolves itself into the treatment of urcemia,
which is as follows, the indications being (1) to eliminate the poison as
rapidly as possible ; and (2) to alleviate the symptoms. In chronic ureemia
a daily dose of Epsom salts may be taken ; the skin must be encouraged
to act ; diuretics such as pot. bicarb, and acet., sp. asth. nit. and scoparium
administered ; and digitalis if the heart is dilated. Large quantities of
water should be taken. To relieve tension and headache nitrogljrcerine is
valuable (see also § 61).

For acute uraemia — muttering deliriimi, convulsions, coma (diagnosis of
ureemic coma, § 530) — ^a brisk hydragogue purgative must be given at once,
such as pulv. elat. co., pulv. jalapae co., or a concentrated solution of
magnesium sulphate. The skin must be made to act by means of hot
packs, hot air or vapour baths, or pilocarpine (i to J grain hypodermically).
Venesection (10 to 20 oimces) did a great deal of good in many of my
infirmary cases, and undoubtedly averted a fatal issue. Transfusion of
normal saline solution (0-75 per cent. NaCl) compensates for the loss of
fluid by bleeding or purgation, and may with advantage be adopted after
venesection. Lumbar puncture with withdrawal of 10 to 15 c.c. of fluid is
beneficial and may arrest convulsions ; chloroform relieves the convulsions.

There is abandant albamen toUh the paasage of larob QUANTrriss of urine, but
litde tendency to dropsy and urcsmia ; t?ie patient has a history of prolonged suppuration,
or of 8 YPmLis ; and there may he evidences of lardaceous disease elsewhere. The disease
is iLkSDACEOUS Kidney.

f 298. Amyloid Kidney (Waxy or Lardaceous Kidney) is generally part of a wide-
spread lardaceous disease involving the liver (enlargement), spleen (enlargement),
and intestines (diarrhcea). With more efficient modem surgical methods amyloid
degeneration is becoming a very rare condition.

410 THE VniNM [f2M

Symptoms, — (1) The albumen, though it may be small in quantity in the early
stage, is very abundant, amounting to three-fourths or more when the condition is
established. Apart from the albuminuria the urine is at first unaltorod, but soon
develops the characteristic changes : (i.) The diurnal quantity is greatly increased,
even to 150 ounces ; (ii.) the specific gravity is very low, but the urea is not diminished
till the later stages ; (iii.) the colour is pale and clear ; (iv.) all varieties of casts may
be found, including amyloid and fatty casts. (2) There is great pallor of the surface
and anaemia, but there may be no dropsy, till quite the end of the disease. In oases
with great cachexia dropsy may occur early. (3) Evidence of lardaoeous disease
in other organs is present — Oliver, spleen, and intestines, consequently hemorrhages
may occur from different parts. The amyloid disease of the bowel gives rise to
very intractable diarrhoea, a symptom which often accompanies amyloid kidney.

It is important for the diayrums to ascertain the history of a cause — ^namely,
(a) prolonged suppmration, either from a chronic abscess, chronic phthisis, or caries.
Dr. Murchison used to be of the opinion that caries of the vertebrsB, even without
definite formation of an abscess, could give rise to lardaceous disease of the viscera,
especially the kidney, (b) S3rphilis is the second of the two great causes which bring
about lardaceous disease.

Prognosis. — ^The course of the disease is protracted. The patient may live for
several years, dying by exhaustion from diarrhosa, or other complications ; very
rarely from ursemia due to the supervention of acute nephritis. With careful treat-
ment patients may live for many years, or even recover if the disease is seen in a very
early stage ; but the prognosis is bad in proportion to (1) the amount of albuminuria,
and (2) the extent of the involvement of the other organs ; it is very good if the septic
focus is removed.

Tre€Umenl. — Alkalies have been reputed not only to prevent, but also to improve,
the lardaceous process — e.g., liquor potasss (6 minims) ; the tartrates and citrates
of the alkalies are also administered. Iodine, especially in the form of iodide of
potassium or iodide of iron, should be given, particularly in S3rphilitic oases. The
most troublesome complication is diarrhoea. The only remedies which in my ex-
perience are of any use are liquor ferri pemitratis (15 minims) ; or pil. plumbi cum
opio (5 grains) continued every four hours until the diarrhoea ceases. Opium may
be administered in this form of renal disease when there is no tendency to ursemia.
The preventive treatment of lardaceous disease consists in the adequate treatment of
syphilis in its early stages ; and in curing prolonged suppuration, especially when this
occurs with chronic profusely discharging ulcers of the leg.

§ 299. In Benal Congestion (Secondaiy Albuminuria) there is some-
times a very considerable amount of albumen in the urine ; but the urinary
and other symptoms do not conform to the foregoing types. Casts are
generally absent, never abundant, and the constitutional disturbance,
apart from the primary malady, is slight.

I/the albuminuria is mabked and constant, and especially if the urinary
symptoms are associated with symptoms referable to some other organ, it is
probably passive reruU congestion due to I. Cardiac Disease ; II. Ascftes
or Abdominal Tumours ; or III. Pregnancy (?).

If the albumen is slight in amount, and especially if it be transient,
it is probably active renal congestion due to IV. Chill to the Surface ;
V. Toxic Blood States, with or without Pyrexia; VI. Drugs;
VII. Dyspepsia or Hepatic Derangement; VIII. Deranged Inner-
vation ; or IX. Functional Albuminuria.

I. Cardiac Disease (the Cardiac Kidney^) is the most frequent of the

^ It is well to bear in mind that when both cardiac and renal disease are present, they
may be associated in three ways : (a) Cardiac disoaso may produce renal disease in

§ 299 ] RENAL CONGESTION 411

congestive causes of albuminuria. Albuminuria is a very common accom-
paniment of mitral valvular disease, and of the dilatation of the right
heart which so frequently follows chronic bronchitis and emphysema.
At first the kidney is only congested, but later the epithelium may become
affected and the interstitial tissue increased. The diagnostic features
of the albuminuria in such cases are : 1. The amount of the albumen
is always considerable, and may be very great. 2. The urine is scanty,
high-coloured, of high specific gravity, and there may be blood-cells,
renal-cells, or even casts ; nevertheless these latter may disappear when
the heart is relieved. 3. There are evidences of the cardiac condition
which has produced the renal disease. In some cases it is difficult to
decide which of these was primary (§ 296, Diagnosis),

Cardiao disease may give rise to renal disease in three ways : (i.) In the manner
just stated, (ii.) Embclism of the kidney is one of the consequences of endocarditis
(acute or chronic). In this condition the albuminuria appears suddenly with hema-
turia and constitutional symptoms, and disappears equally suddenly in a few days,
(iii.) Some causes of aortic valvular disease (the mitral being healthy) have been
attended by temporary albuminuria. The explanation is not obvious. In these
cases the compensatory hypertrophy and dilatation were great, and the arterial
tension high ; and it seems probable therefore that the albuminuria may have been
due to an oc/t've renal congestion.

II. Ascites and Abdominal Tumours. — ^Here the albuminuria is
due to pressure on the renal veins. This condition is recognised by :
(1) The amount of albumen is generally moderate ; (2) there is abdominal
enlargement with the signs of fluid or tumour ; (3) the albuminuria will
disappear on removing the cause. There are two fallacies to be remem-
bered before diagnosing albuminuria as due to ascites: (i.) Both albu-
minuria and ascites may be the product of some common cause — e.g.,
heart disease ; and (ii.) the ascites may be the result of a general dropsy
due to renal disease.

III. Pregnanoy is an undoubted cause of albuminuria, and according
to Playfair it occurs in 20 per cent, of parturient women after the third
month. It also seems certain that permanent and ineradicable renal
disease may, in some cases, date from pregnancy. According to some,
the albuminuria of pregnancy is due to pressure on the renal veins — a
view that is supported by its more frequent occurrence in primiparaB, in
whom the abdominal walls are more rigid. But, on the other hand, the
albuminuria may occur before the uterus is large enough to cause pressure
on the renal veins. These and other considerations point to the con-
clusion that it is probably due to some blood change associated with the
parturient state. The clinical features are : (1) The amount of albumen
is not usually great, and the urine is otherwise normal or very much as
in cardiac cases. (2) Ophthalmoscopic changes (§ 267) may be present ;
but (3) these and the urinary symptoms disappear within two or three

one of the above-mentioned ways. (&) Renal disease may produce cardiac disease,
as when acute nephritis or granular kidney lead to cardiao hypertrophy and failure,
(c) They may botn be the result of a common cause — e,g., gout.

412 THE URINE [§299

weeks of labour unless permanent renal disease has been induced. The
treatment is discussed below.

The remaining causes of albuminuria are probably due to Active
congestion of the kidney.

IV. Chill to thb Surface. — Chill to the surface may result in albuminuria, but
in Buoh oases the kidney is rarely quite healthy. This condition is recognised by :

(1) The amount of albuminuria is never very great, and it does not last for more than
a few days ; (2) the urine is otherwise normal, or may deposit lithates ; (3) the patient,
in other respects, is healthy, or complains only of slight bronchial catarrh or coryza.

V. Toxio Blood States with or without Pyrexia. — ^This cause of albuminuria,
is characterised by : (1) Tube-oasts are absent unless there be active renal disease.

(2) An elevated temperature ; in hyperpyrexia albuminuria is invariably present.

(3) Other evidences of the toxic blood state, namely : (i.) Various acute specific
fevers — e.g,, diphtheria, where albuminuria may be present without high tempera-
ture. In scarlet fever albuminuria frequently comes on between the sixteenth and
twenty-sixth day, at which time also acute nephritis may supervene, and, to avoid
this risk, scarlet fever patients should be kept in bed three or four weeks. Transient
albuminuria may occur in secondary syphilis, between the sixth and eighth weeks
of the disease. If albuminuria occurs in the later stages of the disease, it may be due
to lardaceous disease or gumma of the kidney, (ii.) Acute pneumonia is sometimes*
and (iii.) acute gout is very frequently, accompanied by albuminuria, (iv.) Albu-
minuria may also occur in diabetes (in \%hich it is a grave sign), in pernicious aneamia,
leuksBmia, and the reaction stage of cholera.

VI. Various Drugs, such as morphia, quinine, phosphorus, arsenic, cantharides,
oubebs, copaiba, turpentine, salicylic acid, mercury, and carbolic acid, may give
rise to albuminuria. This cause is recognised by (i.) the presence of the drug in
the urine ; (ii.) there may be a history of the administration of the drug ; and (iii.)
the albuminuria disappears when the drug is stopped.

VII. Dyspepsia and Lfver Derangement are sometimes accompanied by albu-
minuria. The symptoms of hepatic congestion may be present, showing the intimate
connection between the hepatic and renal functions (§ 238). Albuminuria is some-
times present with that form of dyspepsia which is accompanied by oxaluria. Certain
articles of diet are known to have been attended by albuminuria. Thus, cases have
been recorded in which albuminuria followed the ingestion of shell-fish, eggs in excess,
cheese, and large quantities of alcohol. In many of these instances the condition is
probably albumosuria (§ 286).

VIII. Deranged Innervation may be attended by albumen in the urine, such
as (1) bums and other causes of severe shock. (2) In exophthalmic goitre the albu-
minuria is usually a temporary condition, though it may last for months. It may
vary in amount at different times on the same day, which tends to show that it is of
vaso-motor origin. The urine in other respects is healthy. (3) Excessive study
or other cause of nerve strain has been reported to have occasioned albuminuria.

(4) Certain cases of cerebral tumour, and other conditions in which there is increased
intracranial pressure, have been attended by albuminuria. (6) Albumen is found
in the urine after epileptic fits.

IX. Physiological or Functional Albuminuria. — A cyclic form of albuminuria,
or the ** albuminuria of adolescence," has been described. It appears regularly at
some time each day, usually in the morning or after a cold bath. It is usually absent
at night, or when the patient retains the horizontal position, and is possibly therefore
of vaso-motor origin. Hence it is often called postural or orthostatic albuminuria.
Albuminuria has been found in schoolboys and athletes after violent exercise ; it
may last for several hours, but disappears after the night's rest. Paroxysmal albu-
minuria is probably closely related to paroxysmal hsemoglobinuria (below) ; it appears
at intervals, without any apparent cause, and lasts for a few days or weeks at a time.
Some of the reported cases were probably early stages of Raynaud's disease, others
were perhaps associated with oxaluria. Sir A. £. Wright has shown that in functional
albuminuria the renal adequacy is normal, and that the condition is allied to urticaria,
in that it is a serous hsemorrhage due to deficient coagulability of the blood.

S 800 HJBMATUBIA 413

The Prognosis of albuminuria due to oongestion is very much that of its cause.
Before giving a prognosis it is important to thoroughly and repeatedly examine the
urine, for oasts in particular, so as to be satisfied that the kidneys are structurally
healthy. When due to prolonged dyspepsia and liver derangement, interstitial
nephritis may supervene in time if the diet is not properly modified. Young subjects
of functional albuminuria, excluding that form which follows athletic exercise, are
not necessarily predisposed to kidney troubles, but they are often under par ; the
albuminuria may disappear in three to seven years. The prognosis as to life is
excellent.

Treaiment. — ^The treatment must be directed to the cause. Rest in bed will do
a good deal for the renal complication of cardiac disease. In the albuminuria of
pregnancy careful investigations should be made, and the amount of urea watched.
If (1) there is a clear history of renal disease prior to pregnancy, or (2) puerperal
eclampsia has occurred in previous pregnancies, or (3) the renal disease, no matter
of what kind it may be, is distinctly progressive in its nature, then premature labour
should be induced. For the treatment of cyclic and paroxysmal albuminuria general
hygienic and dietetic rules must be followed. The administration of calcium lactate,
by increasing the coagulability of the blood, temporarUy stops the albuminuria in
some of the functional cases.

§ 300. Hsematuria. — When the patient is " passing blood " in the
urine, an endeavour should be made to ascertain if the blood comes chiefly
at the beginning of micturition, chiefly at the end, or whether it is
intimately mixed with the urine and gives to it a " smoky " tint. For
the tests for blood in the urine see § 283. The fallacy of menstrual blood
must be avoided by using a catheter.

A, If the blood is bright crimson and comes chiefly at the commence-
ment of micturition^ it is probably q/* urethral or prostatic origin.

In these circumstances, which are mainly of surgical interest, there will probably
be a history of injury or gonorrhoea. In congestion or abscess of the prostat.e there
are local pains and tenderness and rectal irritation.

B, If the blood comes most freely at the end of micturition^ and especi-
ally if in dots J it is probably o/* vesical origin.

The Commonest Causes of vesical hsemorrhage are :

I. Acute Cystitis, chiefly at its onset (see § 304).

II. Calculus, or stone, in the bladder. Here the haemorrhage is worse after
exercise, moderate in amount, and there is pain, which, like the bleeding, is worse
at the end of micturition and after exercise, and is frequently referred to the point
of the penis. The ensuing cystitis may complicate the symptoms and render the
diagnosis of stone difficult, but its detection by the sound or cystoscope is conclusive.

III. Tumours of the bladder. — The haemorrhage here, especially in viUotts tumours,
is usually great in amount. Shreds of the growth may be passed, and cystitis may
develop. In cancerous tumours the haemorrhage is more or less intermittent and
resists treatment ; there are pain and cachexia, and sometimes the growth may be
palpable above the pubes or per rectum. The cystoscope is the best means we have
of recognising the condition of the bladder.

Some of the less common causes of vesical hsematuria are Tuberculous Disease
of the bladder (when the bacillus may usually be found), Vesical Varix, certain
constitutional diseases such as Scurvy and Purfura, and Bilharzia H^BiATOBiA.

BiLHARZiASis ** Endemic Hsematuria,*' occurs in Egypt and South Africa. It
is due to the presence of a parasitic tromatode. The adult worm is only found
in the portal vein and its radicals, but the ova and liberated embryos migrate
into and block the veins of the bladder, ureters, or kidney pelvis, causing haemorrhage

414 THE URINE I §$01

and great changes in their mucous surfaces. When the rectum is invaded, the papil-
lomatous masses may be mistaken for piles. It is not known how the parasite enters

the body, but it is believed to enter the rectum (some say the
bladder), or to pass through the skin, while bathing. This cause
of hsematuria may be readily detected by the presence of the
highly characteristic ova in the urine (Fig. 89). They are equipolar
ovoid bodies with a spinous projection at one end or one side,
and can be easily seen under a ^-inch objective. The h»mor-
rhage may be very great, and severe anaemia result ; or the
Fig. 89. — Ego of disease may persist with only slight signs for years. The
Swa'^maand?^ P^^'^^ ^^ tosinophilia may suggest the nature of the disease

about 100. Life when occurring in a country where it is rare.

history, Bee Table The Dicignosia and Treaiment of these various vesical conditions
XVII., § 216. (excepting the last-named) is mainly in the hands of the surgeon ;

but temporary relief generally attends rest and the administra-
tion of henbane. Urotropin relieves the vesical s3rmptoms ; large draughts of water
containing benzoic acid (20 to 30 grains daily), and every fourth or fifth day
methylene blue (4 grains t.i.d.) are advised by Lebeau. Sand with recommends ezt.
iilicis liq. nizv. t.i.d. with interval of rest after the fourteenth day.

0. If the Mood is intimately mixed toith the urine, causing it to assume
a " smoky " tint, it is frohally of renal origin. In these cases also the
tests for blood should he carefully apj)lied, and fallacies avoided (§ 283).

The Causes of Renal Hemorrhage may for convenience be grouped
into : Inflammation (I.) ; calculus and other causes of pyelitis (II. to IV.) ;
local conditions (V. to VII.) ; causes from distant parts (VIII. to XI.) ;
paroxysmal hsemorrhage (XII.) ; and parasites (XIII.).

1. In acute nephritis the blood usually gives rise to the characteristic ** smoky '*
urine, and the deposit contains casts (§ 295).

II. Renal calculus (see below).

III. Tuberculous disease of the kidney (§ 305).

IV. Any of the other causes of pyelitis (§ 305) may give rise to red corpuscles in
the urine in larger or smaller amounts.

V. Malignant and other tumours of the kidney, especially cystic kidney, cause
profuse and sometimes intermittent haemorrhage (§ 315).

VI. Villous disease of the pelvis of the kidney.

VII. Injury to the kidney (below).

VIII. Passive congestion of the Iddney — ^for example, in heart disease or chill.

IX. Embolism of the kidney (see Endocarditis, § 39).

X. Blood poisons and blood diseases — ^fevers, scurvy, purpura, etc.

XI. Drugs, such as cantharides, turpentine, and phosphorus.

XII. Paroxysmal haemoglobinuria (below) differs from all the foregoing in the
absence of blood discs, though blood colouring matter is plentiful in the urine.

XIII. Parasites — t.g,, Bilharzia Hsematobia (see above). Filaria sanguinis hominis
usually causes chyluria, but hsematuria also may occur.

§ 801. Renal Calcalns and Renal Colic. — Calculi may form either in
the pelvis of the kidney or, more rarely, in its substance. Perhaps the
commonest form consists of uric add and urates mixed in varying pro-
portions (for tests see § 281). These form stones of light brown colour,
either round or branching, and are the commonest stones in subjects of
the gouty diathesis, and those whose urine habitually deposits lithates.
The other variety, which is dark brown in colour, consists of oxalate of
calcium^ and gives rise to acuter symptoms, for each bristles with sharp-
pointed crystals which wound the mucosa. Calculi are often multiple.

§ 801 ] BENAi;. CALCULUS AND RENAL COLIC 416

Compound stones consisting of an oxalate nucleus, or alternate layers,
are met with. Phospliates are less common and cystine is only rarely
met with in renal calculi. Various events may happen. (1) A calculus
may remain in the renal pelvis, giving rise to chronic pyelitis (§ 305) for
years; or (2) by its movement produce acute symptoms, renal colic.

(3) It may obstruct the ureter and lead to hydro- or pyo-nephrosis (§ 315).

(4) If the other kidney is not healthy sudden blocking may lead to ob-
structive suppression (§ 312). (5) It may pass into the bladder and
result in cystitis. (6) Small stones may be voided through the urethra
as "gravel." (7) In rare cases small calculi become encysted and
quiescent. The typical clinical history of renal calculus consists of
(a) attacks of renal colic, separated by (6) intervals in which the symptoms
are those of calculous pyelitis (§ 305).

The Symptoms of Renal Colic consist of severe paroxysms of lancinating
pain, starting in one loin, shooting down to the testicle or vulva on that
side ; attended by vomiting, shivering, sweating, pallor, and a certain
amount of collapse. These symptoms are in most cases followed by
hsematuria, the urine containing blood discs and pus cells, but usually
no casts. Crystals are also present, and guide us as to the nature of the
stone. It is with the oxalate calculus that most blood and pain occur.
The diagnosis of renal from other forms of colic is given in the form of a
table (Xni., § 172). All the symptoms of renal colic may arise simply
from the irritation of fine crystals. They may also be produced without
alteration in the urine by movable hdney ; or by the passage of dots of
blood or caseous material down the ureter. Malignant disease of the
kidney may be mistaken for calculus, but in that case the blood is
more copious and more constant, and the pain is less severe, but more
continuous. X-ray examination is of assistance except in the case of
uric acid stone.

Treatment, — (1) Of the colic and (2) during the intervals. 1. The
treatment of an attack of renal colic consists mainly in the relief of the
symptoms — pain, vomiting, and collapse. Usually nothing avails except
inhalations of chloroform, and injections of morphia may safely be given
imless there is reason to fear the renal parenchyma is also diseased.
Locally hot applications relieve. Effervescing citrate of potassium with
spiritus ammonisB aromatici may be administered with advantage.
Between the painful attacks the patient must rest to allow the subsidence
of inflammation. 2. The treatment in the intervals resolves itself into the
solution or removal of the stone, and treatment directed to the pyelitis.
Dietetic treatment is of great use in some cases. If uric acid is being
passed, the treatment is the same as that for lithaemia (§ 249). If oxalates
are being passed, any dyspepsia should be carefully treated ; such articles
of diet as rhubarb, tomatoes, cabbages and onions, sweets and alcohol,
should be avoided. The urine in all cases should be kept diluted by
drinking plenty of fluid. The alkaline waters are very useful here, such
as fhose of Vichy, Ems, and Contrex6ville. In uric acid calculus, large

416 THE URINE [§§S08.S0S

doses of alkaline salts are certainly useful, especially the citrate and the
acid tartrate of potassium. Begin with 50 grains of potassium citrate
in 4 ounces of water every four hours until the urine is alkaline, and then
give an efEervescing drink, consisting of 1 drachm of sodium bicarbonate,
and 40 grains of citric acid in 4 ounces of water, three times a day. This
treatment should not be continued if the urine is or has become ammoniacal.
For pyelitis see § 305. Operative treatment is called for if repeated
attacks of colic recur, or if the stone can be detected by radiographic
examination.

Injury of the Kidney, laceration or ruptnre, is usually caused by a fall on the back
or loin, or in ** buffer accidents *' on the railway during shunting operations. There
may be no Imiising or external signs, but a laceration of the kidney may be inferred
from (1) the history of such an accident ; (2) a tense swelling (due to extravasated
blood) with increased area of dulness in the region of the kidney ; and (3) copious
hnmaturia. In a few oases there is no haBmaturia, and the other two evidiences have
to be relied on. Immediate operation is advisable, the collapse being treated by
saline injections.

) 802. In Paroxyimal H»moiAobinnria porter-coloured urine is passed at intervals.
An attack commences abruptly with (I) a rigor or " chilliness," nausea, and malaise ;
and (2) lumbar pain. (3) An hour or so later the patient passes dark, highly albu-
minous urine, showing the spectroscopic band of methtemoglobin or of haemoglobin,
containing no red discs, but a quantity of amorphous granular matter. It has a
specific gravity of 1020 to 1022, a slight excess of urea, and deposits crystals of oxalate
of calcium. Each attack lasts a few hours, and passes off as suddenly as it came,
but only to recur in a few hours' or days* time. In the intervals the general health is
fair, but later the patient becomes ansemic and languid. Kelapses recur for months
or years without fresh exposure to " chill."

The Causes are obscure. The symptoms indicate destruction of blood in the
vessels, with a setting free of hemoglobin which is eliminated by the kidneys. In
90 per cent, of the oases (Roberts) the attacks are connected with chill to the surface.
The disease is sometimes associated with Baynaud's disease, rheumatism, oxaluria
(the sharp crystals of which were thought by some to produce the attacks), malaria,
mental or physical over-exertion, and dyspepsia. It may occur in families.

The Treatment consists of rest in bed during the attacks, with warmth, and hyos-
cyamus internally. Persons predisposed to such attacks should avoid exposure to
cold, and take iron. In one case seen by the author bromide of ammonium had
a marked effect in preventing the attacks.

Symptobiatic HjBMOOLOBii^UBiA may occasionally accompany Raynaud's disease,
malaria, severe bums, and acute infective diseases.

Toxic HjEMOOLOBnrnitiA may be produced by toxic doses of chlorate of potassium,
naphthol, pyrogallic acid, carbolic acid, arseniuretted hydrogen, carbon monoxide,
and quinine in those who have had malaria.

EpiDEBao HjEMOGLOBiNURiA is Seen in the new-bom, with jaundice and nervous
symptoms.

The patient complains of lassitude and iU-heaUhy which have come on
gradually ; the urine is found to contain pus (§ 284) — i.e., there is Pyuria.
With few exceptions {see footnote 2, p, 417), when the pus comes from the
BLADDER the urine is alkaline, and the pus remains diffused through the
urine ; hut when it comes from the kidneys or any other part of the urinary
passages the urine is acid, and the pus settles at the bottom. Pus cells
produce a trace of albumen in the urir^.

§ 308. Pyuria. — ^If we except the rupture of an abscess into the urinary
passages, there are three sources of pus in the urine :

S 804 ] PY VRIA—G YSflTlS 4 1 7

A. From the Urethra (e.g,, gonorrhoea).

B. From the Bladder (cystitis).

C. From the Kidney (pyelitis). — There are three chief forms of pyelitis :
Calculous, Tuberculous, and Ascending.

AbsceMes bunting into the Uruury Tract. — The abBcesses most liable to burst
into the urinary tract are : (a) prostatic abscess (below) ; (b) perineal abscess ; (c) pelvic
cellulitis ; {d) psoas abscess ; (e) perinephric abscess ; and (/) abscess of the liver ;
and there are also many other sources, (i.) The urine is usually acid ; (ii.) the pus
is in large quantity and settles at the bottom ; (iii.) there is a clinical history of abscess
prior to the appearance of pus in the urine ; and (iv.) localising signs of the abscess
may be present.

It is believed by some observers that persons in health may pass a
few leucocytes, but it is extremely probable that these are always derived
from the generative organs (male or female), and that the occurrence of
any pus cells in a properly collected catheter specimen is always patho-
logical.^

When the presence of pus is suspected, the reaction should be tested
immediately after it is passed, before decomposition can set in. Decora-
position makes the urine ammoniacal, and therefore alkaline.

A, The pus comes chiefly at the beginning of BiiOTUBiriON, and the
urine is acid ; it comes from the urethra, and is usually caused by one
of three conditions :

I. Ubethbitis. — ^There is pain, swelling, and redness of t^e meatus, scalding
during micturition, and discharge of pus apart from micturition.

II. Pbostatio Abscess is known by : (1) pain at the end of micturition ; (2) the
finger in the rectum detects a tender, fluctuating swelling ; (3) the symptoms closely
resemble those of vesical calculus with concurrent cystitis. It may be distinguished
from this, however, by : (i.) a history of gonorrhcBa, which is the chief cause of pros-
tatic abscess ; (ii.) the signs on examination per rectum ; and (iii) a discharge occurring
in the intervals between micturition.

III. Pebin^al Abscess is detected by the local signs.

B. The pus comes chiefly at the end of micturition, or is intimately
mixed with the urine, which is alkaline when tested immediately after it is
passed^ {alkaline pyuria). The pus comes from the bladder, and is
indicative of Cystitis.

§ 304. Cystitis^ or inflammation of the bladder, occurs in two well-
recognised forms — acute and chronic.

(a) In Acute Cystitis. — (1) In this condition the pus is in small
amount, and in severe cases there may be considerable heamaturia at the
outset. At first the urine is acid, but it soon becomes alkaline, and ropy
with pus and mucus. (2) There are pain and tenderness in the hypo-
gastrium. (3) Micturition is frequent and painful (" scalding "). After

^ In some cases there is a history pointing to leucorrhcaa or gleet, but the quicl^est
way of settling this point is to draw off the urine by catheter.

^ At the outset of acute cystitis the urine may be acid, and it may become acid again
in the stage of recovery from chronic cystitis. It may also be acid in the earlv stage
of tubercle and new growths of the bladder, and in oases of cystitis due to bacillus coli
communis. In aU other conditions in which the urine contains pus derived from the
bladder the reaction is alkaline.

418 ^tiE VRtNH tJ«^

micturition the pain is relieved for a short time, unless the cystitis is due
to stone in the bladder, when the pain is severe after micturition, because
the inflamed walls of the emptied bladder then come into contact with
the stone. (4) There is generally marked constitutional disturbance,
with pyrexia.

(6) In Chronic Cystitis (which may supervene upon the acute form,
or the cystitis may be chronic from the outset), there is (1) a larger amount
of pus. (2) The urine is markedly alkaline, directly it is passed, and
contains a large amoimt of ropy mucus. (3) The pain and other symp-
toms are less severe than in acute cystitis.

Etiology, — (i.) Gonorrhoea causes the most severe and often fatal form
of acute cystitis and pyelo-nephritis. Other causes are (ii.) stone or
foreign bodies setting up irritation ; (iii.) injury by instruments or foreign
bodies introduced by the patient ; (iv.) the use of catheters which have
not been rendered thoroughly aseptic; (v.) cancer, villous disease, and
other tumours of the bladder; (vi.) urine decomposing in the bladder,
as in stricture urethrse, prostatic enlargement, and other causes of reten-
tion of the urine (§ 311) ; (vii.) various nerve complaints, producing
paraljrsis and retention ; (viii.) extension from a urethritis or inflamma-
tion from adjacent organs, as in pelvic cellulitis ; (ix.) tubercle not infre-
quently affects the bladder, when bacilli are found in abundance ; (x.) other
microbes are now known to affect the bladder, notably the bacillus coli
communis, which produces a mild cystitis, and which is very apt to
ascend (§ 305) ; (xi.) various constitutional states, such as gout and
diabetes, are said to predispose to cystitis; (xii.) drugs — 3.gr., cantharides
or turpentine. The diagnosis of these causes is mainly accomplished
by the surgeon.

Differentiation, — (1) Cystitis due to Vesical Calculus. — In addition to tlie symp-
toms of simple cystitis, there are (i. ) pain at the end of micturition, lasting for some time
after, very severe, shooting down the urethra ; (ii.) hsDmaturia is common, though
in some cases it may be so slight that it is detected only by the microscope ; (iii.) a
history of renal colic (§ 301) ; (iv.) the stone may be detected by the sound or the
cystoscope.

(2) Cystitis due to New Growth in the Bladder, or Ulceration, is charac-
terised by (i.) paroxysms of lancinating pain, quite independent of micturition and
movement ; (ii.) copious hsemorrhage at intervals, occurring without apparent cause ;
(iii.) the urine may contain cancer cells or tubercle bacilli ; a tumour may be felt per
rectum or through the abdominal wall, (iv.) Cystoscopic examination may settle
the diagnosis.

Prognosis. — Cystitis is not dangerous to life unless the inflammation
spreads upwards from the bladder to the kidneys and produces pyelo-
nephritis ; but, on the other hand, it is a very troublesome, painful com-
plaint, and has a special liability to recur. When the cause is not re-
movable— e.g.y in cystitis due to tumours of the bladder — the prognosis
is very grave. When it is due to retention of urine (such as that caused
by the atony of the bladder in old age), and when it is due to gonorrhoea,
it tends to cause ascending pyelitis and pyelo-nephritis. When there
is pre-existing hydronephrosis (§ 315), and acute cystitis develops, the

§t06] PYELITIS 419

inflammation is almost certain to extend upwards to the kidney, and so
lead to pyonephrosis.

Treatment. — The cause must be sought for, and, if possible, removed,
(a) In the acute form absolute rest in bed with milk diet is necessary.
Copious libations of water, barley-water, and other bland fluids are called
for. Alkalies allay the irritability of the bladder. Mild laxatives should
be given, combined with hyoscyamus. Boric acid, 5 to 15 grains, thrice
daily in large draughts of water is valuable. Soothing drugs — e.gr., buchu
and uva ursi — are useful. Hot sitz-baths and morphia suppositories
are given to relieve the pain. It is useful to administer internal antiseptics,
such as quinine and salol, and urotropin (7 grains three times a day).
(6) For the chronic and subacute (non-tuberculous) forms wash out the
bladder with hot water and boric acid. Sir Henry Thompson recom-
mended that it is better to use a strong solution of boric acid, not
exceeding 2 ounces at each sitting, than to wash out with large quantities.
Acid phosphate of soda (gr. xxx. t.d.s.) renders the urine acid,
(c) Therapeutic vaccination is now widely employed, and has proved
of great service in uncomplicated bacterial infection of the urinary tract,
especially tuberculous and coli infections.

0. The pus is associated v)ith a urine which is acid when freshly passed
(add pimria), the jms cdls are at first disseminated through the urine, hut
in a short time they settle down as a sediment, and there are pain, and
j)erhaj)s, swelling of the kidney — the pus comes from the kidney, and
the disease is Pyelitis.

§ 806. Pyelitis, or inflammation of the pelvis of the kidney, is indicated
by the symptoms just mentioned. The urine, which is acid unless there
be concurrent cystitis, contains, in addition to pus cells (Fig. 81), epithelial
cells from the renal mucosa ; but, unless the renal parenchyma is involved,
no casts and no albumen in excess of the quantity which would be
accounted for by the pus are found, nor is there any dropsy. There is
increased frequency of micturition. Renal pain (nephralgia) and tender-
ness are nearly always present, but they vary widely in degree and
character in the three varieties about to be mentioned. The kidney
should always he carefully examined (§ 292), because, in addition to the
renal congestion, all forms of pyelitis are liable to result in partial or
complete obstruction of the infundibula, and the gradual supervention
of hydro- or pyo-nephrosis. A few pus cells in the urine may be found
in acute nephritis, after enteric and other fevers, and toxic doses of
cantharides or turpentine. Apart from these there are three well-marked
varieties or causes of acid pyuria.

1. Calculous Pyelitis is due to the irritation set up by the presence
of a stone. The Differential Symptoms are : (i.) A history of renal colic
(§ 301) is often obtainable, (ii.) Pain on one, the diseased, side, which
varies with exercise, and (iii.) haematuria, also varying with exercise,
(iv.) The quantity of pus often varies from day to day, and the patient
may feel easier after a discharge of pus, as the retained pus causes pain,

420 TUB URINE [§»06

and sometiiues swelling, (v.) Attacks of iutennitteut p3rTexia and
sometimes rigors from time to time, (vi.) Crystals in the urine aid the
diagnosis considerably.

II. Tuberculous PYELrria. — Tuberculous disease of the kidney may
bs primary or secondary to tubercle elsewhere. Very often both kidneys
are diseased. This condition may be very difficult to diagnose from
Calculous Pyelitis, but the Differential Symftams are : (i.) No previous
history of colic, but dull pain in the loins, liable to exacerbations from
the passage of caseous masses ; (ii.) hsematuria is not usually present ; ^
(iii.) the amount of pus in the urine does not vary but steadily increases ;
(iv.) the urine contains amorphous granular matter and tubercle bacilli,
but usually no crystals or tube-casts; (v.) jn/rexia of a regularly inter"
miUifhg type^ with increasing emaciation ; and (vi.) there are often evidences
of tubercle in other parts of the body, as in the testes or lungs ; (vii.) the
cystoscope may show the presence of swelling or ulceration at the mouth
of one ureter ; (viii.) Calmette's and Von Pirquet's reactions are present,
and the opsonic index indicates tubercle {vide § 387).

III. AsoBNDiNO Pyelitis or Pyelo-Nbphritis arises from three groups of causes,
whioh may conveniently be termed Obstruction, Extension, and Infection Pyelitis.
(a) Some obslruction in the urinary passciges below the kidney not infrequently causes
retention and decomposition of the urine, and septic infection of the pelvis of one or
both kidneys, which may go on to pyo-nephrosis. The diagnosis of this form of
pyelitis, which used to be known as '' Surgical Kidney,'' rests mainly on the history
of the cause of retention — enlarged prostate, urethral stricture, uterine and other
tumours pressing upon, or calculus impacted within, the ureter (see also Retention,
§311). Here, as in the next group, the urine may be alkaline from concurrent cystitis.
(6) Ascending pyelitis may also result from the extension of cystitis without obstruc-
tion, and thus the numerous causes of the latter disease (§ 304) are brought into
operation — e.j/., gonorrhoea, septic catheterisation, etc.

(c) Infectivb Pyblo-Nbphbitis is a condition which has been recognised within
the past ten years. Previous bladder symptoms may be slight, transient, or altogether
absent. The nature of the microbic infection which infects the urine is not always
apparent ; but that the b. coli communis is capable of so acting is beyond doubt.
The Symptoms of coli infection may be wholly indistinguishable from calculous pyelitis
on the one hand and tuberculous pyelitis on the other, unless one is aided by the
detection of the respective microbes in the urine. In some cases there is a communica-
tion between the urinary tract and a septic focus, such as a pelvic abscess. In other
cases the organism apparently enters by the urethra, or by the blood-stream. There
are three features which in the author's experience are characteristic of the coli infec-
tion : (i.) the occurrence of attacks of pyrexia at irregular intervals of a disUnctly
pysBmic type, attended by shivering, sweating, vomiting, and pain in the kidney ;
(ii.) a distinctive smell of volatile sulphides in the urine ; and (iii.) the fact that pure
cultures of b. coli cfikn be readily obtained from a specimen of the urine collected
through a sterilised catheter. The disease runs a most indefinite course, but usually
wears itself out sooner or later. It occurs chiefly in women and children, and especially
during pregnancy.

Bacilluria is the term employed to indicate the condition when the symptoms are
more indefinite, less indicative of involvement of the kidney. It is one of the causes of
hectic fever and debility in children, and is only diagnosed on the detection of the bacillL

Urotropin (gr. 5 to 10) and helmitol should be given. Washing out the bladder
is advised by some and condemned by others. In severe oases autogenous vaccines
are employed with success.

^ Occasionally hsematuria is an early symptom of renal tuberculosis. — Dr. Newman,
Lancet, vol. iL, 1899, p. 659.

§806] PYELITIS 421

Prognosis. — (i.) The most serious form of pyelitis is that due to ex-
tension of inflammation upwards from the bladder. When originating
in gonorrhoea! cystitis^ death usually occurs in seven to fourteen days,
(ii.) In the tuberculous form there may be no general symptoms until
the disease extends beyond the one kidney ; in other cases it may be fatal
in twelve to eighteen months, (iii.) Calculous pyelitis may last in-
definitely for years, though not without danger of ursemia and abscess of
the kidney, (iv.) The course of ascending pyelitis depends very much
upon the cause, the possibility of its removal, the age of the patient, and
his general condition. Pyonephrosis (§ 315) may ensue in all the chronic
forms of pyelitis.

Treatment. — 1. In all forms of pyelitis fluid diet, milk and warm drinks,
rest and warmth are essential; and cupping of the loins is sometimes
useful. Sedative drugs, such as hyoscyamus and belladonna, may be
administered, and antiseptics, such as boric acid, quinine, and creosote
may relieve the condition. Buchu, pareira, urotropin, and salol are useful.
Many of these cases call for nephrectomy or other surgical measures.
The question is often raised (before or during operation) whether one or
both kidneys are diseased. The cystoscope here can render invaluable
aid. In all cases daily observations on the amount of urea should be made
(cf. § 280). 2. Of cahulous pyditis. — ^If due to uric acid calculi large doses
of potassium citrate and bicarbonate may be employed ; if due to oxalates,
nux vomica, and nitro-hydrochloric acid ; nephrolithotomy in nearly all
cases. 3. Of tuberculous pyditis. — Tonics such as iron, quinine, and cod-
liver oil must be given. Excision of the kidney is to be advised if (i.) the
other kidney is believed to be healthy ; and (ii.) there is no tuberculous
disease elsewhere in the urinary tract, in the lungs, or intestines. It is
important not to wash out the bladder in tuberculous cases. Tuberculin
treatment, regulated by the estimation of the opsonic index, has given
encouraging results. 4. For ascendir^ pyditis, our attention is best
directed to the cause.

A diminution in the specific gravity when marked and continuous, even
in the absence of albumen, is suggestive of chronic iNTERSTrriAL nephritis,
or more rardy diabetes insipidus. A marked increase in the specific
gravity is suggestive o/*diabetes mellitus.

§ 306. The other canses of altered specific gravity are relatively less
important, because they are identified mainly by other means. Never-
theless, the specific gravity of the urine is an extremely important feature,
because, in the absence of sugar, it is a measure of the nitrogenous
and SALINE EXCRETION, the specific gravity being higher in direct pro-
portion to the amounts contained in a given sample of urine. Therefore,
with certain reservations about to be mentioned, it is a very fair measure
of the FUNCTIONAL ACTIVITY of the Secreting substance of the two kidneys
taken together. For example, when one kidney is known to be diseased
or destroyed, it will give us a good idea of the condition of the other,

422 THE URINE [§I67

and in Blight's disease we may learn something of the amount of renal
epithelium undamaged. In such cases regular estimations of the urea
secreted should be made (§ 280). The reservations just alluded to are
four in number : (1) the specific gravity must always be considered in
relation to the total diurnal quantity of the urine ; (2) the total urea
varies considerably with the body weight, being less in women and persons
of slight build ; (3) it varies to some extent also with the amount of proteid
food ingested, and the work done by the body — thus it is rather less in
a person lying in bed ; (4) it b assumed that the liver is healthy because,
as mentioned in the introduction to Chapter XII., the first stage in the
manufacture of urea takes place there, only the concluding stage being
performed by the kidney.

The variations in the total output of urea have been mentioned under
the several diseases of the kidney.

The specific gravity is diminished in —

1. Chronic Interstitial Nephritis.

2. Polyuria, and all the diseases about to be mentioned under that heading, except-
ing Diabetes Mellitus.

3. Myxoedema and other conditions where the nitrogenous disintegration within
the body is diminished.

The specific gravity is increased in —

1. Diabetes Mellitus (owing to the sugar).

2. Some renal diseases where the quantity of water is considerably diminished,
such as Acute Nephritis or the CSardiao Kidney.

3. Febrile and other conditions where the nitrogenous disintegration is excessive.

4. Whenever the urine becomes concentrated by profuse sweating, vomiting, or
diarrhoea.

An increase (Polyuria), or diminution, m the Quantity of mine is
comflained of by the ^patient in several important diseases.

§ S07. In Polyuria it is very desirable to measure the total diurnal
quantity, since patients are very apt to mistake increased frequency
for increased quantity, and vice versa.

There is increased quantity of urine secreted in —

1. Diabetes meUUus, which is known by the high specific gravity of the urine and
persistent glycosuria.

2. Diabetes insipidus — ^low specific gravity and malaise, but no sugar.

3. Chronic interstilial nephritis, which is known by the low specific gravity of
the urine, slight albuminuria, etc. (§ 297).

4. Waxy kidney, which is known by the low specific gravity of the urine and great
albuminuria (§ 298).

5. Hydronephrosis, which is known by the passage of large quantities of urine
for a limited period of time, accompanied by the disappearance of a swelling from
the loin. This is followed by a return to the normal both in quality and quantity
of the urine, and then a gradual re-formation of the swelling (§ 315).

6. Convalescence after fevers.

7. Temporary polyuria occurs in hysteria, , nervous excitement, chlorosis, Dietl*8
crises, alcoholism, and any other condition giving rise to reactionary or paralytic
condition of the abdominal sympathetic. Cerebral tumours may be accompanied
by polyuria.

8. During the administration of diuretics.

9. During the absorption oj exudations, such as pleural effusion.

§§ 808. 800 ] POL YURIA--DIABETES MELLITUS 423

There is diminished quantity of urine in —

1. Aoate Nephritis.

2. Subacute and Chronic Tubal Nephritis (some stages).

3. Final stage of Chronic Interstitial Nephritis.

4. The Cardiac Kidney and some other Renal Congestions.

5. Febrile states.

6. Whenever there is profuse vomiting, diarrhoea, or perspiration, or but little
fluid is taken.

The pdtient complains q/*pol3niria ; the urine is o/hiqk specipio gravity,
and CONSTANTLY contains sugar (glycosnria) ; there are also thirst, and,
in sfite of a voracious appetite, gradual loss of flesh. The disease is
Diabetes Mellitus.

§ 808. Temporary Olycosuria may arise in many conditions in which the carbo-
hydrate metabolism is deranged. Often it is of little or no consequence. (1) Dietetic
errors (gl3roo6uria only after a meal). (2) Qradual occlusion of the portal vein.
(3) After large or prolonged doses of certain drugs — chloroform, chlond, morphia
(the reaction here may be due to glycuronic acid). (4) After epileptic convulsions.
(5) During the collapse of cholera. (6) During the paroxysms of ague. (7) In
chronic Bright*s disease with high tension. (8) Cardiac disease, asthma, pertussis,
and some other cases of dyspnoea. (9) Injury to the liver. (10) Congestion of the
liver in gouty people, and when much exercise is taken by those unaccustomed to it.
(II) Intestinal irritation. (12) After concussion and compression of the brain,
and tumour, especially if involving the floor of the fourth ventricle, the pituitary or
pineal glands. (13) Violent mental and moral emotions. (14) During pregnancy and
suckling. (15) Pancreatic disease. (16) Diseases of the thyroid. (17) After acute
fevers such as influenza or diphtheria.^

§ 809. Diabetes MeUitus is a constitutional disease, characterised by
the passage of large quantities of urine containing glucose, associated with
progressive emaciation and voracious appetite. 1. There is usually
increased frequency of micturition, and the patient passes large quantities
(6 to 40 pints) of clear pale urine, which has a sweetish odour. If
dropped upon the boot, this leaves a crystalline deposit, by which means
the condition has occasionally been recognised. The specific gravity is
high — 1,030 to 1,040 or more. The amount of sugar varies from 2 to 40
grains or more per ounce, and the total amount per day varies from
10 ounces to 2 pounds. In diabetes the sugar may occasionally disappear
for several days, but in general terras it is permanent and persistent.
The diurnal quantity of urea and phosphates is increased ; diacetic acid
and acetone may be present, and albuminuria sometimes, especially towards
the end. 2. Progressive weakness and emaciation are sometimes the first
symptoms to attract notice. 3. At other times thirst or voracious appetite,
accompanied by a raw beefy tongue and dry skin, are the first signs.
4. The complications (vide infra) not infrequently lead to our detecting
the disease, for its earlier stages are often overlooked by the patient.

Varieties, — There are two well-marked varieties of diabetes : (a) The
mild form, which is met with in corpulent middle-aged people, where
the symptoms are moderate, and dietetic restriction removes the sugar
from the urine. This is really a transient glycosuria, (b) The severe

^ Glycosuria is fully dealt with by Dr. A. E. Garrod, the Lancet, February and
March, 1912.

424 THE URINE [§809

variety is met with in acute and chronic fonns. The acute form usually
occurs in children or young adults, and occasionally after head injuries.
The chronic form is met with in older people, and is attributed sometimes
to mental worry. It also occurs with tumour of the fourth ventricle and
other causes of transient glycosuria which become chronic.

Causes. — ^Diabetes occurs in the proportion of three males to two
females, and may be hereditary. Gout, insanity, or phthisis may bo
present in the family. Sedentary habits and brain overwork may pre-
dispose. The pathogenesis is not at present known, but it is certain
that the pancreas is fibrotic in about 50 per cent. Physiological evidence
also points in this direction. It is probable, also, that the glycogenic
function of the liver is in some way interfered with, possibly indirectly
through the pancreas.

The Complications of diabetes are numerous. In order of frequency
they are : 1. Phthisis^ which is one of the moat frequelit causes of death
in the condition. 2. Various sJdn conditions, especially eczema, boils,
pruritus, and xanthelasma, which appear early in the disease, and car-
buncle and gangrene, which appear in the later stages. It is essential
to examine the urine for glucose in all cases of boils, carbuncles, and
pruritus vulvae. 3. The nervous system is specially apt to be affected, and
peripheral neuritis is now known to be frequently caused by diabetes.
The knee-jerks are commonly lost in diabetes, sometimes without any
other nerve symptom, or there may be tingling, numbness, perforating
ulcer, or neuralgia. Restlessness is common, and this may go on to mania
or melancholia. The sudden supervention of diabetic coma often ter-
minates life. 4. Ocular changes are almost as common as the foregoing,
and these may take the form of soft cataract, or defective accommoda-
tion leading to a rapidly increasing presbyopia. Retinitis, optic atrophy,
and amblyopia also occur.

Diagnosis, — In any of the conditions mentioned imder Comjdications
the urine should be examined. This is the key to the diagnosis. In
diabetes insijndus, granular kidney, amyloid kidney, and sometimes in
hysteria the quantity of urine is excessive, but in none of these conditions
is sugar present. Two golden rules will often enable us to identify a case
of diabetes which otherwise might be overlooked : 1. Always examine
the urine of a patient suffering from boils or from eczema of the genitals ;
and 2. of a patient the subject of apparently causeless wasting. For
the diagnosis of diabetes from temporary glycosuria vide supra.

Prognosis. — 1. The mild form, which is met with chiefly in corpulent
persons and others over thirty-five, may occasionally pass into the graver
form, but generally with suitable diet the sugar disappears, and the
condition warrants an excellent prognosis. 2. In the severer forms the
prognosis chiefly turns upon the age of the patient. If the disease is
established in a young adult, life rarely lasts more than two years at the
outside. The effect of diet is a valuable aid to prognosis. If by this
means the sugar can be reduced to 3 or 4 grains per ounce, the patient

§ see ] DIABETES MELLITU8 425

may live many years, especially if the disease did not come on until middle
life was reached ; if, on the other hand, 10 or 20 grains are constantly
present, the case will go rapidly downhill. The presence of complicaHons
other than pneumonia or phthisis does not add very materially to the
gravity of the situation. Death may ensue in three ways : (i.) By com-
plications— a third of the cases die of phthisis; (ii.) by asthenia; and
(iii.) about an equal number die with coma. Coma is heralded in most
caseis by certain symptoms which it is well to bear in mind. Such are a
decrease in the amount of urine, the occurrence of albuminuria, a Tapid
increase in the urine of the fatty acid series, viz. : /^-oxybutyric acid,
diacetic acid, and acetone (§ 287), epigastric pain (often severe), increasing
languor, a sighing respiration with extensive thoracic movements (" air-
hunger "), and drowsiness. In some cases the coma supervenes suddenly,
after a period of excitement. A peculiar sweet odour in the breath, due
to acetone, is often a valuable means of diagnosis of diabetic coma.

The chief Treatment is dietetic, and consists in the reduction of sugars
and farinaceous foods. A strict dietary is given in § 212. The amount
of sugar in the urine should first be estimated, and then the carbohydrates
gradually diminished, until the sugar has been brought as low as possible.
Milk and a little bread should be retained, unless they seriously afiect
the amount of sugar passed. The tendency is to be more lenient in the
dietary than heretofore, but each case requires individual study. Too
strict exclusion of carbohydrates leads, even in severe cases, to the appear-
ance of acetonuria, necessitating intervals of relaxation in the strictness
o'f the diet and the free administration of alkalies for a time. Some can
assimilate a small amount of carbohydrates if they have plenty of fresh
air and exercise, or if they take one particular form of carbohydrate. Thus,
some do better with potatoes than with other forms of starch ; some c^n
tolerate sugar if in fruit. Von Noorden has good results from a diet of
oatmeal for several days, followed by a few days of vegetable food. Many
of the advertised starch-free breads are by no means what they claim to
be ; the careful physician should examine them for starch with the iodine
test, and for sugar by boiling them with dilute sulphuric acid, neutralising
with caustic potash, and adding Fehling's solution. Saxin is taken in place
of sugar. Among therapeutic agents codeine, one of the alkaloids of
opium, still takes the first place. It is given in increasing quantities
from J grain to 6 or 8 gr. t.i.d. Taka-diastase has been given with promising
effects ; the patient can assimilate more carbohydrate during its adminis-
tration. Professor Ebstein recommends sodium salicylate. If diarrhoea
is present, opium may be given, and very large doses are tolerated.
Uranium nitrate has done good in some cases. Arsenic, bromides, and
antipyrin are used, especially when the nerve structures are affected.
Among the symptomatic indications, thirst is best allayed by frequent
doses of dilute phosphoric acid; the voracious appetite and dyspepsia
may sometimes be allayed by bismuth. Coma has not hitherto been
successfully treated by the ordinary means, but cases have been reported

426 THE URINE [§810

of recovery after large intravenous saline injections, to which 1 to 2 per
cent, of sodium bicarbonate should be added. If coma is threatened, as
shown by the presence of diacetic acid and increase in acetone, more carbo-
hydrate must be allowed ; levulose is useful in this respect, for, although
a carbohydrate, it does not increase the amount of sugar in the urine.
Large doses (Ji. to Jii. sod. bicarb.) must also be administered by the
mouth, or Jii. to 1 pint of water may be injected by the rectum.

Pancreatic Diabctai is described as a special variety, but some cases of Diabetes
Mellitus have been observed with pancreatic lesions, such as chronic inflammation
and fatty degeneration. They have been characterised by the presence of undigested
fat in the fsBces, and the ordinary symptoms of a severe diabetes running a very rapid
course. In chronic pancreatitis and pancreatic calculi, glycosuria is often present.
On the other hand, pancreatic disease may be unattended by glycosuria.

The patient ccmplains of polsmria and many of the other symptcms of
Diabetes MeUituSy hut the specific gravitt of the urine is low, and
there is no sugar. The disease is Diabetes Insipidus:

§ 810. Diabetes Intipidui is characterised by great and persistent increase in the
quantity of the urine, without glycosuria and albuminuria, attended by great thirst
and emaciation. It is believed to be due to a dilatation of the renal vesseb, though
how this permanent dilatation occurs is uncertain. The fact that the condition occurs
with tumours of the medulla or pons, or with lesions involving the thoracic or
abdominal nerve ganglia, is strongly suggestive of a vaso-motor paralysis.

Symptoms. — (1) The amount of urine may be very great, from 10 to 20 pints per
day. It is pale in colour, so that it may resemble clear water. The specific gravity
averages 1002 to 1005. The diurnal amount of solid constituents is as a rule not very
much increased, and no other abnormality may be present. Occasionally traces of
albumen and sugar appear towards the end. (2) In the mild form of the disease
polyuria and thirst are the only symptoms ; but in the severer variety nearly all the
symptoms mentioned under Diabetes Mellitus are also present — dry skin, emaciation,
large appetite, and alternating constipation and diarrhoea. Indeed, it is distinguished
from that condition only by the absence of glycosuria. Intercurrent attacks of
pyrexia have been observed. (3) Obscure nervous symptoms, with irritability of
temper, are common in this disease — such as disturbed sleep, occipital headache,
neuralgic pains in the lumbar region, diminished reflexes, and muscular twitchings.

Diagnosis. — ^The disease is apt in its early stages to be mistaken for chronic inter-
stitial nephritis, but the greater age of the patient, the presence of traces of albumen,
and of cardio-vascular symptoms, and the absence of thirst and voracious appetite
distinguish the latter condition. With amyloid kidney there is albumen, and with
both hydronephrosis and cystic kidney a tumour is generally palpable in the region of
the kidney. In Diabetes MeUitus there is glycosuria.

Causes. — (i.) More males are affected (two or three to one female). Childhood
and early middle age are the favourite ages, (ii.) It is said to occur in association
with a nervous temperament. Certainly among the chief exciting causes are injuries
to the nervous system, especially blows on the head. Intracranial tumour or in-
flammation or powerful emotions are also exciting causes, (iii.) Muscular exertion,
exposure to cold, and intemperance are also mentioned.

Prognosis. — ^The milder varieties may last for a great many years, and exist rather
as an inconvenience than as a malady. In the severer forms, especially those due
to intracranial tumours, the course may be very rapid, and death ensue in the course
of a month. When setting in acutely after injury to the head (which may be attended
by some glycosuria at first) recovery may ensue after a year or so. In children with
the tuberculous diathesis death usually occurs in the course of one or two years. In
general terms, cases setting in acutely are more hopeful than those which start in-
sidiously. Death may take place from gradual exhaustion, drowsiness passing into

H »!. S18 ] DIABETES INSIPIDUS-^SUPPRESSION 427

coma, with or without oonvulsions, or from oomplioations such as phthisis or
pneumonia.

Treaiment. — Most reliance is placed upon hygienic treatment. Tea, coffee, and
other substances which increase diuresis should be avoided, but the amount of fluid
taken should not be reduced below that excreted. Of drugs the fayourite is valerian
gr. V. of the powdered root, increased up to 5i' Nitroglycerine has been used, and
large doses of antipyrin (up to 5i. daily) have given good results. Arsenic relieves the
gastro-intestinal and skin symptoms. When there is disease of the bulb, electricity
may be tried — ^the positive pole placed on the back of the neck, the negative pole
passed through the nostril to rest on the cervical spine, } to 5 milliamperes for five
minutes every second day.

The jxUierU complains that he eannot pass water, and a distended
BLADDER can be made out by percussion and palpation above the pvhes, or
by the passage of a catheter. The condition is Retention of Urine.

§ 811. The Causes of Retention of Urine come mainly within the
province of the sui^eon. Those of sudden onset are often due to urethral
spasm or congestion ; those of gradual onset are more numerous. The
age and sex of the patient may aid us. Thus, in childhood we may suspect
impacted calculus, phimosis, or a ligature round the penis; in wom,en,
tumours pressing on the neck of the bladder (e.g., fibroid or retroverted
uterus), hysteria, or reflex irritation after parturition ; in young or middle-
aged aduUSy stricture, gonorrhoea with congested mucous membrane,
spasm after exposure to cold or a drinking bout, or tabes dorsalis ; in
old men, prostatic enlargement, or atony of the bladder. At all ages
there may be calculus or tumour blocking the neck of the bladder, paralysis
of the bladder from diseased or injured cord or brain, or reflex spasm after
operations about the perineeum.

The Treatment is mainly surgical, but in cases of spasm a hot bath or
hot fomentations to the abdomen will give relief. Hysterical and other
nervous afiections are referred to elsewhere. Atony and simple vesical
paralysis may be treated by nux vomica, and the constant current, one
pole being placed on the perinaeum and the other just above the pubes.

The patient complains that he has not passed any water for some time,
hut there are no evidences of a distended bladder, and on passing a
catheter it is found to be empty, or nearly so. The condition is Suppres-
sion OF Urine.

§ 812. Snpiiression of Urine is a very grave condition. A catheter
should always be passed before the diagnosis of suppression is made.
There are two kinds : I. Obstructive suppression, which is due to some
obstruction to the flow of urine through the ureters; and II. Non-
obstructive suppression, which is due to the non-secretion of urine by
the kidneys. This latter form is sometimes spoken of as true suppres-
sion.

I. Obstructive Suppression is due to blocking of both ureters (the
kidneys being healthy) by (i.) renal calculus ; (ii.) tumour at the base of
the bladder; (iii.) congenital malformation of the ureters. When only
one ureter is completely blocked, the urine that passes is clear, of low

428 THE URINE [§S1S

specific gravity, and non-albuminous; and chronic ursemia ensues until
the condition is relieved or the remaining kidney undergoes compen-
satory hypertrophy (see also Hydronephrosis, § 315). When both ureters
are blocked, a condition known as " latent urcemia " arises. The Symptoms
are : the patient passes no urine for about a week, and may complain
of nothing except slight drowsiness, but after eight or ten dayB he becomes
restless, with contracted pupils, subnormal temperature, dry brown
tongue, and muscular twitchings. In other cases vomiting may be so
severe as to suggest the presence of intestinal obstruction. Death is
usually sudden, after ten to fourteen days, the mind remaining clear to
the end.

II. The causes of Non- Obstructive Suppression are : (i.) Acute
nephritis, or the terminal stage of chronic nephritis (ten to twenty hours
before death) ; (ii.) collapse (of which suppression is one of the symptoms)
— e,g,, after abdominal operations or injuries, passage of a catheter, fevers,
or local inflammations ; (iii.) hyisterical anuria ; (iv.) acute lead, phos-
phorus, or turpentine poisoning ; (v.) embolism or thrombosis of both
renal arteries (very rare). Whichever of these causes is in operation,
the Symptoms are : (1) any urine passed is high-coloured and concentrated
(high specific gravity), and may contain albumen and casts (indicating
that the suppression is due to renal disease) ; (2) there may be urgent
vomiting, diarrhoea, and sweating. The other symptoms are those of
acute uraemia (§ 270) and those of the cause.

Prognosis, — Suppression is a very serious symptom, though the gravity
depends somewhat upon the cause. Of the obstructive forms, calculus
blocking one ureter, the kidney of the opposite side being healthy, is perhaps
the most favourable. If the obstruction afiects both ureters and is not
removed, death will occur in about eleven days after the obstruction began.
In the non-obstrtictive forms death or partial recovery takes place in a
few days.

Treatment. — ^Hot baths, pilocarpine, and other diaphoretics promote
the action of the skin, and so relieve the toxaemia. Free purgation
promotes the excretion by another channel ; cupping, wet or dry, over
the loins relieves the local congestion. For the treatment of obstructive
suppression a surgeon should be called at once.

The patient complains that his urine dribbles away constantly, and on
percussing over the pubes or passing a catheter, his bladder is found to be
empty. He has True Incontinence. Or he complains^ that he has a
frequent caU to uriruUiony and cannot cdways hold his water. He has Active
Incontinence.

§ 818. Inconlinence of Urine may be of two kinds, and it is best to
speak of these as True Incontinence and Increased Frequency
(Active Incontinence) respectively.

(a) True Incontinence, when the urine dribbles away involuntarily
as fast as it is formed, must not be confused with overflow or alse vncon-

§ 818 ] INCONTINENCE OF URINE 429

ti/Mfnce, which is due to the overflow of a distended bladder in retention.
The latter is recognised by the percussion signs of a full bladder and by
the relief afforded by the passage of a catheter. In true incontinence,
which is relatively a rarer condition, the Cause is generally quite apparent,
such as vesico-vaginal fistula, paralysis and dilatation of the sphincter
after the operation of lithotrity, or the paralysis of the sphincter associated
with various cerebro-spinal afiections.

(6) Increased Frequency op MicTURmoN, or, as it is (unfortunately)
sometimes called. Active Incontinence^ is a very common complaint. The
patient can hold his water, but the calls to urinate are too frequent, and
sometimes so urgent that a few drops dribble away before arrangements
can be made. The normal time during which the urine can be retained
varies in dilEerent individuals, and also according to the amount of fluid
taken ; but four to Ave hours is a fair average. It is longer in the female
than the male ; some women can retain the urine for ten or twelve hours.
The habit is injurious, and i^ said to lead t^ flexions of the uterus.

Increased frequency is due to many Causes, The first point to deter-
mine is whether there is any marked increase in the diurnal quantity,
as in diabetes or chronic granular kidney, because any of the causes of
polyuria (§ 307) may be a cause of increased frequency of micturition.
In young adults diabetes is perhaps the commonest, but in advancing
years granular kidney and enlarged prostate are by far the most common
causes. Indeed, our attention is often first drawn to the latter condition
because the patient develops a habit of rising at night to pass water.
It is not always easy to decide whether the quantity is increasied or not,
as the patient is apt to think that, because he passes water too often,
he passes too much. But having as far as possible excluded polyuria, there
remain three groups of causes to consider : 1. Some cause of heal irritation
is imdoubtedly the most frequent. The urine may be too acid. The
bladder may be irritable, as from the presence of an enlarged prostate
(the usual cause of abnormal frequency in old age), chronic cystitis, ulcera-
tion, tumour, stone (in the young) oxaluria, or pressure upon the viscus
by a displaced uterus. Or the irritation may be in the kidneys from the
presence of stone, tubercle, or other cause of pyelitis (§ 305). Or the
irritation may be reflexy from disease in the vicinity of the bladder, worms,
phimosis, or too long a prepuce (a very frequent cause of nocturnal in-
continence in children), fissure, piles, prolapse or polj^us of the rectum,
vascular urethral canmcle (a cause frequently overlooked in women),
pelvic inflammation, or varicocele. 2. Constitutional causes are occa-
sionally associated with this condition, such as hysteria, sexual excesses,
adenoid vegetations in the pharynx, and other causes leading to deficient
aeration of the blood. 3. A congenital want of development of the sphincter
is sometimes present. True congenital cases are rare, and defective
action of the sphincter is more frequently due, especially in women and
children, to some of the reflex causes above mentioned, the habit per-
sisting after the cause has been removed.

430 THE URINE [ § S14

Nocturnal Incontinence in children is a troublesome condition often
met with in private practice. In such cases we must first satisfy ourselves
of the absence of any organic disease. Having done this it is well to
remember in this condition that it may be associated with incipient
insanity in childhood, general debility, stone in the bladder, and adenoid
vegetations in the pharynx. The last named, if severe, result in a deficient
aeration of the blood and an unduly heavy deep. The other causes
mentioned above should also be remembered.

Both Prognosis and Treatment turn almost entirely upon the cause,
and are hopeful in proportion as this is removable. The power of re-
tention of the urine is a habit which can be cultivated in early life, and
the relative frequency in different individuals varies a good deal with
habits engendered in childhood. Careful local examination should always
be made to exclude local causes. If the urine is acid, or the bladder
irritable, much good may be done by the administration of alkalies and
hyoscyamus. If the bladder is wanting in tone, belladonna and nux
vomica are the two sovereign remedies. Tincture of rhus aromatica,
\]{y. to Il\xv. has been found to be useful where no causs is obvious, and
thyroid extract has been recently recommended.^ If there is irritability
of the nervous system bromides are specially useful. Children of faulty
habits may be treated by sleeping on hard mattresses, or by preventing
them sleeping on the back by means of a reel of cotton fixed to the sacrum
by plaster. They should be made to pass water before going to bed.
Raising the foot of the bed and cold douching to the spine are recom-
mended. Parents should be cautioned against punishing children for this
nocturnal incontinence.

§ 814. The urine presents a dondiness, due to some crystalline or
OTHER DEPOSIT ; it may be urates, uric acid, phosphates, oxalates,
or FAT, unless it be pus (§ 288), blood (§ 283), or bacteria (§ 288).

In lithnria the urine, clear when first passed, becomes cloudy, with a
pinkish amorphous deposit when it gets cold ; the deposit dissolving again
when heated in a tuhz. The condition described as LrrH^BMiA (the clinical
condition associated with lithuria) is still by most believed to be due to
functional derangement of the liver, and its symptoms are described
in the disorders of that organ (§ 249). Various other conditions with which
excess of urates and uric acid in the urine may be associated, as a more
or less subordinate symptom, have already been referred to in § 293.

The clinical significance of uric acid and urates is still a subject of

debate.

Phosphatnria is usually indicated by cloudiness in a neutral or alkaline urine (§§ 285
and 291). (1) Phosphates frequently occur in the urine in such quantity as to cause
a turbidity even when first passed. They are apt to occur especially towards the end
of micturition, not infrequently alarming the patient unnecessarily. Phosphates

^ Dr. Leonard Williams strongly advocates the use of thyroid extract, gr. J ter die.
cautiously increased, combined if necessary with Calcium Iodide, gr. ii.. and liq.
Arsenicalis, »aii. (" Adenoids, Nocturnal Enuresis, and the Thyroid Gland " (John
Bale and Sons, 1910).

i S14 ] DEPOSITS IN THE URINE 4S1

may be especially abundant in the alkaline '* tide " of the early morning, or after
dinner, lliere may be no symptoms, even when phosphates are passed in large
quantities ; but more frequently phosphaturia is accompanied by chronic dyspepsia,
or some condition in which the urine is alkaline. Phosphates are thought by some
to be an evidence of excessive nerve waste ; I have seen several cases of phosphaturia
in medical men who had recently undergone severe brain work and nerve strain.

(2) The name Phosfhatig Diabetes has been given to a condition where there
are thirst, emaciation, aching pain in the loins and back, and an increase of phos-
phates in the urine, the diurnal quantity of which is greatly increased. The urine
is alkaline or very feebly acid in reaction. In diabetes mellitus the phosphates vary
inversely as the sugar. Phthisis may supervene, or the disease may pass into diabetes
mellitus or diabetes insipidus, if unrelieved by treatment.

(3) There i? an increase of phosphates in wasting diseases, severe ansomias, and in
convalescence from fevers.

(4) Phosphates are diminished in acute fevers, and in diseases of the kidney —
e.g., nephritis.

(5) Stellar Phosphates may indicate grave constitutional disturbance — e,g., diabetes
and cancer. Trifle Phosphates found in freshly passed urine denote that decom-
position is going on in the bladder, an indication of cystitis. It is liable to deposit
within the bladder or to form stone.

The Treatment of " phosphatic diabetes *' is by rest, warmth, and light nourishing
food. Alcohol and coffee should be forbidden, as they promote diuresis. Codoia
or opium should be administered until pain is abated ; when tonics, iron, quinine,
nux vomica, and cod-liver oil should be freely given.

Ozaluiia is generally indicated hy a '* powdered wig " deposit on the top of the mucus
which settles at the bottom (§ 291). Transient oxaluria has no clinical significance
except as indicating the nature of a stone, which has revealed its presence by other
symptoms. It is aXao found after a diet of rhubarb, tomatoes, cabbage, or onions.
But oxaluria is also connected with other clinical conditions.

(i.) In the oxaluric dictthesis there is an excessive formation of oxalates in the
urine. Gases have been recorded where the symptoms of rapid emaciation and
pains in the loins and back were attended by an excess of oxalates in the urine. ^
(ii.) Pancreatic disease, (iii.) Other observers have connected certain nervous
symptoms, such as mental depression going on to neurasthenia and even melan-
cholia, with oxaluria. It is probable, however, that these symptoms are connected
with the concurrent dyspepsia, (iv.) Oxaluria very often seems to be connected
with dyspepsia. Urates are generally precipitated in the urine at the same time
as the oxalates, and Sir Lauder Brunton has shown that the passage of sul-
phuretted hydrogen through a strong solution of urates gives rise to the formation
of oxalates, by its reducing or deoxidising power. In intestinal dyspepsia a large
quantity of this gas is formed in the intestines, and it seems probable that oxaluria
in these cases may be caused by the deoxidising or reducing power of the H2S upon the
urates, (v.) Oxalates are found in large excess in paroxysmal hsemoglobinuria (§ 302).

Fat may occur in the urine in chronic tubal nephritis attended by much fatty
degeneration of the epithelium, and after fractures of the bones. It is found in
great abundance in Ohylnria. The presence of chyle in the urine gives to it a milky
white appearance and the power of coagulating. Chyluria is not imcommon in the
tropics, where it is due to the migration of the filaria sanguinis hominis from the
lacteals into the urinary tract, the unnatural communications thus made leading to
the paroxsymal appearance of chyle in the urine. The urine passed at night is the
more completely white ; that passed by day may be mixed with blood. The embryx)s
of this parasite are to be found in the urine with a few red and white blood - cells,
albumen, fat, and shreds of fibrin. However, other cases have been observed in
persons who have never resided in the tropics and in whom no parasite can be found.
The causation of such oases is obscure. (Chyluria may follow trauma, and it may
accompany leukaemia in rare cases.

* Cantoni, " Oxalurie." German translation by Hahn; Berlin, 1880; Begbiei
Schmidt's Jahrbh., Ixvii., 52, 1850 ; and Jaksch, op. eit,, p. 307.

432 THE UBINS [§S15

Prognosis. — The |)atieut may live tweuty years with but little impairment of
health. In other cases, however, great debility and mental depression may bo

present.

Treatment, — Prevent the disease by boiling the drinking-water. Gallic acid is
recommended. To meet the drain on the system give plenty of food.

§ 315. Renal Tumours may be of six kinds : (I.) Hydronephrosis ;
(II.) Pyonephrosis; (III.) Perinephric Abscess; (IV.) Malignant
Disease ; (V.) Cystic Disease ; and (VI.) Movable Kidney. The last-
named is described under Abdominal Pain (§ 177), which is the symptom
for which advice is sought. Extravasation of blood after injury to the
kidney may simulate a tumour (§ 301).

The Physical Signs common to all tumours of the kidney, and their
diagnosis from other abdominal, tumours, are given in §§ 188 and 292.

I. Hydronephrosis is a term indicating a cystic tumour of the kidney,
caused by the gradual obstruction of the urinary passages, and the conse-
quent dilatation of the pelvis of the kidney.

The Symptoms by which this tumour is recognised are : (1) At intervals
a large amount of urine passes, with concomitant reduction or even dis-
appearance ot the tumour. The urine is pale, clear, and of normal com-
position. (2) Constitutional and general symptoms may be absent.
(3) Local pressure symptoms may arise, causing pain or disturbance of
function of the neighbouring organs.

Etiology, — The causes of obstruction to the outflow of the urine may
be (i.) congenital (contracted or twisted ureters) ; (ii.) oc^tred causes, which
may occur (o) in the urethra, such as stricture or enlarged prostate;
(6) in the ureter, such as occur from stone or blood-clot ; pressure by pelvic
or other tumours ; contraction after operation, injury, or disease of the
ureter; or kinking, as in movable kidney. These acquired causes give
rise to a gradual obstruction, and when the obstruction is intermittent
the tumour may become very large, when it is liable to be mistaken for
an ovarian cyst, or even for ascites. In such cases a trocar may be
introduced, and the fluid withdrawn would reveal an absence of the
albumen which is always present in an ascitic fluid.

Prognosis, — If the condition is unilateral and intermittent it may
cause little trouble, and may disappear after a duration of years. On
the other hand, a double hydronephrosis is very serious, as it leads to
ursemia. The surgeon should be called in early. The complications are
rupture into the peritoneum or pleura ; the onset of suppuration in the
pelvis of the kidney (pyonephrosis) ; or uraemia, due to atrophy of the
substance of both kidneys.

Treatment, — If the tumour is intermittent, imilateral, and causing few
symptoms, it is best to leave it alone. Osier recommends the use of a
pad to retain the organ in place and prevent further dilatation.^ If the
tumour becomes very large, surgical treatment is advisable. In all cases
the cause must be ascertained and, if possible, treated.

^ Piofeesor William Osier, ** Abdominal Tumours." 1894.

§ »15 ] RENAL TUMOURS 433

n. Pyonephrofif is a cystic tumour of the kidney due to distension of the pelvis and
calices by fluid containing pus. It is consequent on obstruction to the free outlet
of the urine in septic cases of pyelitis, or sepsis supervening on hydronephrosis.

The Symptoms are : (1) The tumour is tender to palpation ; (2) symptoms of pyelitis
are present — pyuria, intermittent pyrexia, sometimes rigors, and dull pain in the loin ;
(3) at intervals, when the obstruction is removed or diminished, the tumour may
subside, coincident with the passage of a large quantity of pus in the urine.

The Causes are : (1) pyelitis (§ 3C5), with blocking, partial or complete, of the ureter ;
or (2) hydronephrosis {vide Causes of this above) becoming septic — e.g,, from extension
upwards of cystitis.

Diagnosis, — (1) From hydronephrosis, which has no tenderness or fever ; (2) from
perinephric abbess, which has greater tenderness in the loin and a more superficial
swelling, with local signs of abscess sooner or later.

Prognosis. — ^The condition is very grave. A tuberculous pyonephrosis may under-
go cure by fibrosis ; but in most cases the patient becomes worn out with long dis-
charge, or develops amyloid disease, or a fatal issue is rapidly brought about by the
tumour bursting into the abdomen or chest.

Treatment is mainly surgical, and nephrotomy is indicated. The cause must be
treated medically.

m. Perinephric Abfoeis is not very uncommon. It may arise by (i.) extension
from kidney disease (pyelitis) ; (ii.) extension from a perityphlitic abscess ; (iii.) ex-
tension from other organs — e.g,, abscess of the liver, empyema or spinal caries ;
(iv.) after an injury. The Symptoms are : (1) dull, aching pain in the loin radiating
down the leg ; (2) deep-seated resistance in the hypochondrium in front, tender to
pressure ; (3) the temperature is continuous, or pysemic in acute cases with sudden
onset, or intermittent in insidious cases ; (4) the leg on the same side is kept flexed
and the patient stoops when walking ; (5) swelling, with oedema of the skin, which
appears late in the disorder, is felt between the iliac crest and the last rib, and it may
be fluctuant ; (6) the urine may or may not be altered according to the cause, but
traces of albumen are common. The Diagnosis is difficult in the early stage when
pain alone is present, when it may readily be mistaken for lumbago or spinal disease,
but there is no fever in the former. Later it may be mistaken for a renal tumour,
but in a simple tumour fever is absent, and the leg would not be held constantly
flexed ; the aspirating needle may be used. In pyonephrosis there is not such acute
pain or tenderness. Prognosis. — ^The abscess tends to open or to burrow its way in
various directions, into the alimentary or urinary canals, peritoneum, or pleura.
It may point in the lumbar region or various other directions, and burrow for a con-
siderable distance. Treatment. — In the early stages, before the diagnosis can be cer-
tain, give hot fomentations and opium for the pain ; as soon as pus is recognised
operative procedure is necessary.

ly. Malignant Diiease itarting in the Kidney is certainly a rare condition, as it
has only been foimd in about I in 500 autopsies on persons dying of malignant
disease.^ It affects children under nine (in whom sarcoma chiefly occurs), and adults
over forty (in whom it is usually carcinoma), there being a remarkable immimity between
these age periods.^ Benal sarcoma is the commonest abdominal growth in children,
and it is believed often to start before birth. According to Bland -Sutton, it is met
with in the first five years of life, and then, after a period of immunity, is found again
in people between fifty and sixty.

The Symptoms are : (I) The tumour is rapidly growing, usually of firm consistence,
but if of very rapid growth it may appear fluctuating ; (2) hsematuria, frequent, inter-
mittent, and of moderate amount ; (3) progressive emaciation ; (4) the pain is variable,
sometimes it is very severe, owing to pressure upon or infiltration of the neighbouring

1 Discussion on Benal Tumours, Path. Sec. B. M. A., 1899.

^ The solid tumours affecting the kidney consist of {A) Connective tissue type : —
I. Simple or benign growths (fibroma, lipoma, angioma) ; II. Sarcoma, which is by
far the commonest. (B) Growths of an epithdicS type : — ^I. Adenomatous growths
(simple adenoma, trabecular, and papilliform cystomata) ; II. True Carcinoma : —
(1) glandular type ; (2) malignant papilloma. {U) Adrenal inclusions. (/>) Adrenal
growths. — " Renal Growths, T. N. Kelynack, Manchester.

434 THE URINE [ § 815

organs. Sometimes pain is entirely absent, and the tumour may have attained a very
large size before any symptoms occur.

Diagnosis. — ^When a tumour occurs in a movable kidney it is apt to be mistaken
for ovarian tumour or fibroid, and vaginal examination is necessary (see § 188 for
diagnostic points). Tvberculous kidney in a child may present difficulty, but the
pain is less, and pyuria is present rather than hsBmaturia. Pyonephrosis is accom-
panied by fever, the swelling is fluctuant, and there is a history of pyuria. Retro-
peritoneid and renal sarcoma are the chief causes of enormous abdominal tumours
in children. The diagnosis of malignant tumours is not usually difficult.

The Prognosis is very grave. If untreated, death occurs in six to twelve months
after detection of the growth, the cancer of adults being of somewhat slower
growth.

Treatment is usually too late ; early excision gives the only chance of life.

y. Oyitio Disease of the Kidneys is a rare condition, usually of congenital origin,
in which both kidneys contain cysts of varying size and number.

Varieties, — (i.) The cystic kidney in ite typical form is a mass of cysts, and is usually
congenital ; (ii.) cystic kidney may arise in connection with granular kidney ; in this
variety the tumour is never so large as in the former ; (iii.) cystic formations may
also be due to hydatid.

Symptoms. — (1) There is a swelling usually in both lumbar regions, of insidious
growth, very hard at first, and later yielding. (2) The other symptoms are similar
to those of chronic interstitial nephritis — the urine is abundant, pale, of low specific
gravity, containing traces of albumen, and occasionally blood and casts. The heart
becomes hypertrophied, and the pulse indicates high tension. The patient may have
excellent health for many years, or may develop symptoms of chronic urssmia.

The Diagnosis may be difficult. When symptoms of granular kidney occur,
together with a tumour in both renal regions, the condition may be diagnosed as
Cystic Kidney. The tumours have to be diagnosed from other abdominal tumours
(§ 188).

Causes. — ^The disease may occur in the foetus. Patients with the above symptoms,
however, are usually men over middle age. Out of twenty-one cases coUected by
Dr. W. H. Dickinson, eleven were over forty.

Treatment is similar to that of Bright*s disease. Death may occur from ursemia
or the same complications as those of interstitial nephritis.

Hydatid cyst may occur in the kidney, and may be difficult to differentiate from
other cysts unless it opens into the pelvis of the organ, when the characteristic booklets
(§ 254) are found in the urine. The passage of vesicles may cause renal colic. The
condition may be suspected if (i.) the tumour has the ** hydatid thrill ** on palpation ;
(ii.) there is evidence of the presence of cysts elsewhere ; and (iiL) there is a history
of residence in affected coimtries. (iv.) Eosinophilia is present.

The Prognosis is not grave. The cyst may last for years without symptoms, or it
may burst into the pelvis of the kidney. It may open into the stomach or bowel,
with alternate recovery ; or into the chest, which is a serious complication. It may
become very large and give rise to pressure signs.

Treatment is surgical.

CHAPTER XIV

DISEASES PECULIAR TO WOMEN

The symptoms and consequences which may arise from disorders of
the female genito-nrinary organs are very numerous and widespread.
Indeed, there is hardly a physiological system which does not suffer
when these organs become affected. It is on this account that they
should receive more attention from the general physician than is the
custom.

PART A. SYMPTOMATOLOGY.

§ 316* The symptoms proper to these organs may be divided into
local and general. The Local Symptoms are certain external conditions
around the vaginal orifice, leucorrhoea (vaginal discharge), dysmenorrhooa
(painful menstruation), menorrhagia (excessive menstruation), amenor-
rhcBa (deficient menstruation), pain in and around the organs, various
disorders of function (e.g., dy^pareunia and dysuria) and tumours of the
uterus.

The General SYSfproMS consist of (1) malaise and general ill-health,
which is often quite out of proportion to the amount of local mischief.
A life of chronic invalidism not infrequently supervenes upon some chronic
though slight derangement of the reproductive organs. This general
wealmess is specially apt to affect the nervous system, and one is some-
times tempted to credit the older authors who named hysteria on account
of its supposed origin in the womb (wtc/oos). (2) " Dyspeptic " symp-
toms of a reflex kind are nearly always present, as in other disorders con-
nected with the abdominal viscera. (3) Anaemia is another consequence,
though this may be due in part to the confinement indoors, or to the
" loss " in cases of excessive menstrual flow. (4) Various neuralgise and
a general hypersensitiveness of the sensory and sensitive apparatus.
A certain degree of this is normal during the menstrual periods, and as
civilisation advances it seems as though this recurrent hypersensitiveness
Were increasing. By degrees, especially in those who suffer from dys-
menorrhcea, this undue generalised hyperaesthesia is prolonged into the
intervals between the periods.

Case-takiiiflr in diseases of women differs somewhat from that given

485

436 DISEASES PECULIAR TO WOMEN [§817

in Chapter I. The following summary will form a guide to the principal
questions to be answered as a matter of routine :

1. What is the leading symptom oomplamed of by the patient ?

2. History — name, age, married or single, (a) If married, how long 7 How
many ohil(Lren ? Date of last confinement ? Any miscarriages ? Confinements
easy or difficult ? How long in bed after the birth ?

(5) Menstruation — age at which it commenced 7 (i.) Regular ? Twenty-eight
day or thirty-day type ? Lasting — three, five, seven days 7 (ii.) Blood coming
in clote (means excess) ? (iii.) Painful or not ? Pain dated back to a particular
time ? Pain in small of back, shooting down one or both legs, or in ovarian region ?
Pain persistent or paroxysmal ? Wliat relation to the flow 7

(c) Any intermenstrual discharge — duration ; quantity ; white, clear, or thick
and yellow ; offensive ; or with d6bris and blood.

{d) Micturition — painful, dribbling, or too frequent. Condition of bowels — pain
on defsBoation 7

(e) Other physiological systems to be inquired into ; and whether general health
has suffered.

PART B, PHYSICAL EXAMINATION,

§ 317. Except in certain circumstances, an abdominal and local
examination should be a matter of routine in all gyneecological cases
which are not on the surface obvious. There are four methods by which
the female pelvic organs can be investigated.

(a) An External Examination of the abdomen — inspection, palpa-
tion, percussion, auscultation (§ 166).

(6) A VuLVO-vAGiNAL EXAMINATION should uot be undertaken with-
out duly considering both the necessities of the case, and the feelings of
the patient. The patient should lie on the back, with the legs both drawn
up at an acute angle ; the light should come from the foot of the couch.
Note by inspection the colour and condition of the vulva, hymen, urethral
orifice, and the condition of the perineum, especially in women who have
borne children, and then proceed to pass the finger gently. Some use
the first, others the second finger ; it is useful to be able to use either hand,
so that we may keep one hand for possibly septic cases alone. The
finger-nails should be kept extremely short and smooth, both for the
patient's comfort and for cleanliness.^ As a lubricant for the finger some
physicians like sanitas with vaseline (about 5 per cent.), others use
carbolised glycerine (1 in 200). When there is much vaginal discharge
rubber gloves should be worn lubricated with glycerine. The finger is
passed well in, and the condition of the vaginal walls noted ; the position
and condition of the cervix, whether patulous and soft as in pregnancy,
firm, granular, figured, conical, etc. Note also any fixity of the uterus,
and whether there is an angle or dip between the cervix and body anteriorly
or posteriorly such as occurs in flexions.

^ A story is told of the late Mr. Lawson Tait, whom a great many foreigners used to
visit. One particularly insistent gentleman, who generally had long dirty nails, was
always seeking to ascertain from him the secret of ms success. Lawson Tait, who was
not in the haoit of measuring words, became somewhat annoyed at the insdstenoe of
his visitor, and one day in reply to the oft-repeated question, he said : " The secret of
my success is that I keep my nails short and extremely clean."

§ ai7 ] PH Y8ICAL EXAMINATION 437

(c) It is very desirable to make a Bimanual Examination next in
order. Instruct the patient to lie on her back, to draw up the legs, and relax
the abdominal muscles. With the finger of the right hand in the vagina,
the physician places the left hand firmly above the brim of the pelvis,
so as to be able to manipulate the uterus between the two hands. Note
the size, position, and mobility of the uterus, the presence or absence of
tumours, displacements of the uterus, or pelvic swellings or exudations.
The bladder must be empty, and the rectum if possible.

(d) Various instruments are of considerable aid.

1. The Sound must be used only with strict antiseptic precautions. Undoubtedly
hann used to be done by passing it through a septic vagina into the uterus. Its use is
contra-indicated in (i.) pregnancy, (ii.) menstruation, (iii.) acute inflammation in the
pelvis, (iv.) cancer, and (v.) it should never be passed before making a bimanual ex-
amination.

With the tip of the right forefinger against the os pass the sound along the palm
of the right hand until it slides well into the cervix. Then by a gentle turn and by
a veiy gentle pressure upwards the sound will pass upwards and forwards into the
uterine cavity.

The uses of the sound are to discover : (1 ) the depth of the uterus, which is normally
2^ inches, and the thickness of its wall ; (2) the position of the uterine cavity, when
it is impossible to find it by bimanual examination ; (3) the state of the endometrium ;
(4) the size of the os ; (5) the presence of tumours in the uterus.

2. Vaginal Speculum. — Many different specula are in use. Practically they are
of three types. The Ferguson, which is a tube ; the bivalve or trivalve, which consists
of two or three limbs jointed together ; and the duckbill, which consists of two separate
pieces. The first is best for the examination of the os ; the second for the examination
of the walls of the vagina ; and the third for operative measures. In passing it do not
forget the vaginal canal is directed backwards and upwards, and less pain is produced
by quick movements in the right direction than by slow bungling. Note the con-
dition of the mucous membrane, and the character of any discharge. If it be desirable
to make some application to the interior by means of a Playfair*s probe, this should
be done before withdrawing the speculum.

3. The volseUum is a hook for drawing down one or other lip of the cervix, which
is desirable, for example, (i.) for the introduction of tents. It is also of use to examine
(ii.) any catarrhal patch, (iii.) where the uterus is freely movable, and (iv.) to
palpate the posterior surface of the uterus. It is contra-indicated in those conditions
in which the sound is contra-indicated, and also in tubal pregnancy.

Dilatation or the Cervix may be done by two methods :

1. Slow Method, — Sea tangle, tupelo, or sponge tents are inserted into the os uteri,
and left in sOu for some hours. By the absorption of fluid they swell up and distend
the cervical canal. This method is useful in nulliparous women or when the cervix
is rigid. It is little used nowadays.

2. Rapid Method. — Hegar's or Fenton^s dilators are usually employed. They
are vulcanite or metal instruments of graduated sizes. General ansesthesia is neces-
sary. Having inserted the duckbill speculum, fix the anterior lips of the cervix with
the volsellum or ovum forceps, draw well down, and insert the dUators gradually one
after the other until the cervix is large enough to examine the interior with the finger.
In this way one can curette the interior if there is any granular endometritis, or make
a digital examination of the endometrium, which is possible only after much dilata-
tion. The nature of any growth present is discovered by a microscopic examination
of the scraping ; such examination should never be omitted. Dilatation of the cervix
is contra-indicated in tubal disease, possible pregnancy, or cancer of the cervix.
It should be performed with great caution when the tissues are softened by recent
pregnancy.

438 DISEASES PECULIAR TO WOMEN [ §§ 818, 819

PAET G. DISEASES OF WOMEN, THEIR DIAGNOSIS, PROGNOSIS,

AND TREATMENT,

§ 318. Routine Procedure and Classification* — Having ascertained the
patient's principal or Leading Symftom, and the leading facts as to the
History, according to the scheme given in Part B., proceed, unless the
nature of the case is not already apparent, to the Physical Examination
(s'lbject to the reservations mentioned in Part B.).

Classification. — The diseases of the female reproductive organs may

be arranged, like urinary disorders, under the various cardinal symptoms

to which they give rise — ^viz. :

(a) Morbid alterations of the vulva and external parts - - § 319

(6) Leucorrhoea - - - - - - - § 320

{d) Hsemorrhage - - • - - - § 322

(/) Pelvic pain, acute (§ 331), chronic - - - - f 335

{g) Pelvic tumours - - - - - - - f 336

(h) Pain on sitting, dispareunia, dysuria, and other disorders of

function- - - - -- - -f 340

§ 819. Morbid Alterations of the Vulva. — ^A few of the conmion altera-
tions are enumerated here.

Vulvitis in children may be caused by the migration of round worms,
by uncleanliness, debility, gonorrhoea, or bad habits. In adults it is
generally accompanied by vaginitis (q.v.).

Pruritus Vulv^ (itching) is sometimes a very troublesome condition.
An examination should always be made to discover whether eczema,
pediculi, or irritating discharges be present. If these be absent diabetes
may be suspected,

EozEMA of the vulva is, in the author's experience, greatly on the
increase, as a consequence, in his belief, of the modem fashion of wearing
closed non- washable Igiickers.

Caruncle is a minute red irritable papilloma situated usually just
within the urethral orifice. It is a frequent cause of painful micturition,
painful sitting, and painful coitus. There is also a painless form.

Slight prolapse of the urethra may give rise to a red swelling which
may be mistaken for a canmcle.

Labial Thrombosis is readily recognised, and is a not infrequent condition in
certain hyperinotic states.

Absoess of the vulva sometimes foUows the last named. Sometimes it occurs as
an inflammation of Bartholin's gland.

Herpes is an eruption of a smaU group of vesicles. They readily rupture, leaving
round superficial ulcers which may become infected secondarily.

Noma, Diphtheria, Chancres, Condylomata, Ulcers (simple or malignant)
also affect the part.

In the Treatment of vulval conditions cleanliness is essential, and on
the whole the lack of this is one of the most frequent causes of vulvitis.
It is surprising what little attention is paid to this matter, as is shown
by the immense quantities of epithelial cells which are habitually found

§ 820 ] LE UGORRUiEA 439

in the urine. Any eczematous or local condition must be treated as
elsewhere. Caruncle is best treated by strong nitric acid or Paquelin's
cautery. Labial thrombosis requires surgical treatment. Pruritus vulvae
may in my experience often be cured by large doses of calcium chloride.
Cases which have long resisted other treatment have yielded to this.^
Locally, lotio calaminse co. in weak carbolic acid solution, liq. carbonis
detergens, and sodium bicarbonate and borax solution are employed in
varying conditions. Li cases where the itching is very intense, a solution
of nitrate of silver (20 grains to the oimce) may be painted on, the parts
having been first anaesthetised by the application of cocaine solution.
At the same time use internal remedies, such as arsenic, quinine, urotropin,
and bitter tonics. For herpetic ulcers use 5 per cent, nitrate of silver,
and then zinc oxide paste.

§ 820. LencoirhcBa is any white or whitish discharge from the vulval
orifice (colloquially known as the " whites "), due to excessive secretion
from the mucous lining of the genital tract. It may be caused by an
unhealthy condition of the mucous membrane of the Fallopian tubes,
or of the body or cervix of the uterus, or of the vagina. For a correct
diagnosis of the cause it is necessary to make a culture from the discharge.

(A) Leucorrhcea of Vaginal Origin arises when there is vaginitis
from any cause, either acute or chronic.

(a) In Acute VAGmms the discharge is profuse, yellow or greenish,
and sometimes blood-stained, attended by dysuria and local signs of
inflammation. The chief Ca'uses of acute vaginitis are : (1) Traumatism,
due to pins, peas, and worms in children, or in the adult an irritant
pessary, or other foreign body (such as a letter), too powerful injections,
or excessive coitus ; (2) gonorrhoea, which is hard to diagnose from non-
specific acute vaginitis except by the microscopic examination of the
discharge ; (3) spread from adjacent parts, and (4) a diphtheritic form.
A severe acute vaginitis is probably of gonorrhceal origin,^ and the danger
of this rests in the liability to endometritis, pyosalpinx, peri- or para-
metritis, cystitis, and ascending pyelitis. The Treatment consists of rest,
saline purges with hyoscyamus to allay the pain, copious warm drinks,
hot hip-baths, and douches of carbolic (1 or 2 per cent.), potassium per-
manganate (10 grains to the pint), or corrosive sublimate, and after a
few days some astringent lotion such as sulphocarbolate of zinc (2 drachms
to the pint), glycerine of subacetate of lead (4 drachms to the pint). Pro-
targol (4 per cent.) may be applied through the speculum.

(ji) In Chronic Vaginfiis there is a thick, continuous, opaque dis-
charge, with or without local signs of inflammation, according to the
cause in operation. The Causes are (1) antecedent acute vaginitis ;
(2) various constitutional conditions, such as general debility, strumous

^ The Lancet, Auffost 1, 1896.

^ The b. ooli, diploooooi of various kinds, fuugi, and other pyogenic infections, also
cause acute vaginitis.

440 DISEASES PECULIAR TO WOMEN [ § 920

(i.e., tuberculous) diathesis, diabetes, old age, alcoholism, anaemia, syphilis,
rheumatism, and convalescence from fevers; (3) new growths in the
vaginal walls, such as epithelioma ; (4) irritant foreign bodies and other
causes mentioned under Acute Vaginitis. The Treatment consists of the
appropriate remedies for any constitutional disease present, combined
with warm douches (100° F.), containing sulphate of zinc or sulphate of
copper, or the remedies mentioned under Acute Vaginitis. Local applica-
tions are made with Ferguson's speculum, and a cotton swab dipped in
2 per cent, iodine solution or silver nitrate solution (5 per cent . ) . Medicated
pessaries may be used at night.

(B) Leuoorrhcea op Uterine Origin may be due to endocervicitis or
endometritis, cancer of the uterus (see Hsemorrhage), concurrent peri-
or para-metritis (see Pelvic Pain), and, lastly, to constitutional causes such
as gout, rheumatism, or ansemia.

I. In Endocervicitis (Cervical ENDOMETRms), or inflammation of
the cervix, the discharge is more or less constant, and usually consists of
glairy material like white of egg, but it may be muco-purulent. The other
symptoms are : (1) The cervix is swollen, and may present retention cysts,
but more usually on examination with the speculum one sees an " erosion "
or catarrhal patch, which may bleed slightly on pressure ; (2) menorrhagia
or dysmenorrhoea and backache are frequently present. Endocervicitis
may have to be diagnosed from cancer of the cervix. Here the age is not
much guide, as cancer of the cervix may come on in a patient as young as
twenty-six. Cancer is hard to the touch and is friable, readily breaking
down and bleeding when touched, and there is usually a blood-stained
discharge. Microscopic examination of scrapings will determine the
diagnosis. When fixity of the uterus and cachexia have appeared, the
diagnosis is simple. For Causes and TreatmerU see below.

II. In Endometritis, or inflammation of the body of the uterus, the
discharge comes in gushes when the patient rises or walks about ; and in
the senile it may be blood-stained. Endometritis is usually accompanied
by both menorrhagia and dysmenorrhoea, and general pelvic discomfort
and pain. The general health may be poor. Bimanually, the uterus is
found to be enlarged, and the sound reveals also enlargement and dilata-
tion of its cavity ; the cervix is often hypertrophied and inflamed. Some-
times there is a history of recurring abortions or of sterility. Endometritis
may require to be diagnosed from cancer. Owing to the risk of delay,
curettage should be performed, and the scraping thus obtained determines
the diagnosis.

The Causes of endocervicitis and endometritis are classified thus :
(1) Bacterial invasion — gonorrhojal, diphtheritic, septic, and other in-
fections, spreading upwards; or from retained products after labour or
abortion, or the use of dirty instruments ; (2) congestion of the uterus,
as in displacements, tumours, injury, subinvolution, tumours of the adnexa,
excessive coitus, constipation ; cardiac, pulmonary, and renal disease ;
old age:

§ 381 ] D YSMENOERHCEA 441

TrecUment, — Endometritis and endocervicitis require first a cert-ain
amount of hygienic and general treatment, especially if there has been
much menorrhagia. Displacements and other causes of congestion must
be rectified. The special organism responsible for any infection must be
treated. For endometritis resisting such treatment there are two methods
of local treatment : (1) The application of strong carbolic or other corrosive
to the interior by means of Playfair's probes ; (2) dilatation of the cervix
and curetting the interior. Endocervicitis is treated by applications of
silver nitrate or copper sulphate (gr. xl.-,^i.) applied by a Playfair's probe,
passed through a Ferguson speculum to protect the vaginal wall ; or by
cataphoresis (see Dr. S. Sloan, the Lancet, July, 1909). Erosions may
be cauterised. Hot douches are used twice or thrice daily (never less than
a quart at a time) ; and tampons of ichthyol (10 per cent, in glycerine)
are inserted after the douches or applications. Operative treatment may
be necessary.

§ 321. DysmenorrhcBa is pain during the menstrual period. There are
three varieties : (I.) NeIuralgio or Spasmodic, in which the pain is par-
oxysmal, and may be so SBvere as to cause vomiting and collapse. It is
situated chiefly in the hypogastrium, begins a few hours before the flow,
and lasts for one to two days. (II.) In the Inflammatory form the pain
is dull, aching, persistent, situated sometimes in the small of the back,
and down the legs, begins several days before the flow and is relieved by
the flow, especially when it is profuse. (III.) In the Membranous variety
the pain is severe, paroxysmal, and relieved as soon as the membrane is
passed. In the first named, local examination reveals nothing wrong in
the uterus or its appendages, and the menstrual flow is usually natural.
In the second variety, examination generally reveals some abnormality
in the uterus or its appendages — e,g,, endometritis, fibroids, adhesive
bands, ovaritis; and it not infrequently dates from a confinement or
abortion. The third is diagnosed by the passage of a membrane, and
is distinguished from abortion in that it is passed every month.

Causes, — The causes of neuralgic dysmenorrhoea are of a general
character, like those which lead to neuralgia in other parts. The causes
of varieties II. and III. are such as lead to inflammation of the uterus
or its appendages. All three varieties have been variously ascribed to
obstruction of the flow by flexions of the uterus, or by constriction of
the cervix, or to the undue excitation of uterine contractions.

Treatment. — I. The neuralgic form usually calls for general treatment
— hygienic, dietetic, and tonic. Treatment directed to the diathesis,
as in rheimiatic persons (guaiacum resin, gr. x.), may effect a cure. It is
very important in this and in the other varieties to avoid constipation.
Warm baths, and especially Turkish baths, are very valuable in my
experience. Remedial treatment at the time of the period consists of
hot bottles to the hypogastrium, hot drinks, feet in hot water, cannabis
indica, liquor sedans, ergo-apiol, belladonna, camphor, sal volatile.

442 DISEASES PECULIAR TO WOMEN [ § 822

bromides, castor, antipyrin, and morphia (with great caution). In
obstinate cases dilatation of the cervix often lessens the severity of the
attacks. Childbirth usually cures the condition.

II. The inflammatory form admits of the same symptomatic treatment
as the foregoing. The remedial treatment should be directed to the
inflammatory lesion which is the causal agent. Depletory methods, such
as a glycerine tampon, leeches, or scarification of the cervix, combined
with a saline purge, are indicated. Antipyrin is of little use ; alcohol
increases the pain. Styptol (gr. J to J) may aid. Very hot douches
(110** F. for ten minutes) should be given twice daily. In severe cases
removal of the appendages has been adopted.

m. For the membranous form the symptomatic treatment is as above,
with the subsequent dilatation and curetting of the interior during the
interval.

mtteliohmeil is a rare condition in which pain is felt at regular intervals between
the menstrual periods. It is not so severe as spasmodic dysmenorrhoBa. Its cause
is unknown.

§ 322. Haemorrhafire. — Menorrhagia indicates an excessive flow at the
monthly period ; Metrorrhagia indicates irregular haemorrhage from the
uterus, irrespective of the period. It is difficult to separate these two
symptoms, as their causes are more or less identical, and they very often
occur together. Haemorrhage from the vulva or vagina is usually slight
in quantity, and its cause readily discovered by inspection. Haemorrhage
from the cervix is usually due to polypi, malignant disease, tuberculous
or sj^hilitic ulceration. Rarely it is due to erosion or injury by a pessary.
All of these are made out on inspection. Haemorrhage after coitus is
suggestive oi malignant disease.

Haemorrhage from the uterus may be due to the following causes :
Endometritis, constitutional conditions, fibroids and polypi of the uterus,
pelvic inflammations, fibrosis or metritis, subinvolution of the uterus,
malignant disease, retroverted uterus incarcerated in Douglas' pouch,
ovarian tumours (occasionally), inversion of the uterus, and extra-uterine
foetation. Flexions and versions of the uterus rarely cause symptoms
unless attended by pelvic inflammation or adhesions.

In women over thirty- five the above causes also may give rise to haemor-
rhage, but in addition it may be due to the Menopause. The sudden
supervention of metrorrhagia with acute pain should always suggest a mis-
carriage or an extra-uterine foetation (§ 328).

In women past the menopause some gross lesion of the uterus, especially
Cancer or Uterine Fibroid, is nearly always present.

Many of these conditions are dealt with elsewhere, but menorrhagia
or metrorrhagia is the chief symptom referable to the reproductive organs
in : (I.) Certain Constitutional conditions ; (II.) Uterine Fibroid or Polypus ;
(III.) Subinvolution (in persons under thirty) ; (IV.) the Menopause ; and
(V). Malignant Disease (in persons over thirty). These conditions will
therefore be differentiated here;

§§ 828, 824 ] HJEMORRUAQE 443

§ 323. Hfiemorrhage may depend upon certain constitutional con-
ditions. (1) Certain women of a plethoric habit of body, usually with
florid countenances, may be troubled with too profuse periods all their
lives, and a tendency to excessive flow on any trivial exciting cause.

(2) Prolonged lactation or too many and too frequent pregnancies;

(3) residence in tropical climates ; (4) acute specific fevers ; (5) mental
over- work, especially if combined with a sedentary life, are said to produce
it. (6) The vague condition we call hysteria, especially in that variety
which is subject to flush storms, is frequently attended by menorrhagia.
(7) The congestion in the circulation which attends some heart and liver
diseases finds more or less relief in this way. (8) Menstruation may be
very profuse at the onset of the function at puberty. The differential
characters of the bleeding due to these causes are : (1) The menstruation
may occur every third or second week, or even weekly, though in point
of quantity it may or may not be increased. The flow, moreover, may
be very readily excited, as by a hot bath, or after a day of unusual exercise.
(2) The general symptoms after a time point to anaemia, combined with
the symptoms of the constitutional cause in operation.

§ 324* Haemorrhage may, secondly, be due to a uterine fibroid.
The symptoms vary with the position of the tumour. These tumours
may be submucous, interstitial, or subserous. When the fibroid is Sub-
mucous or interstitial, the symptoms of uterine fibroid are (1) menor-
rhagia and metrorrhagia. (2) Leucorrhoea and sometimes dysmenor-
rhoea are present. (3) On examination with the sound the uterine cavity
is found to be enlarged ; and (4) on bimanual examination enlargement
of the uterus, which is usually hard and bossed from the presence of more
than one fibroid, can be detected. There is a tendency for the submucous
variety to become polj^oid, remaining attached to the uterus by a pedicle.
The subserous fibroid may present no symptoms at all for many years
and may even then be discovered by accident. Amenorrhoea may accom-
pany such cases quite as often as menorrhagia, and the latter is never
profuse. In short, pressure symptoms may be the earliest indication of
a subserous fibroid. In uterine fibroids of all kinds the rate of growth,
though it varies somewhat, is nearly always very slow ; but as the tumour
increases we get symptoms of pressure upon the surrounding organs, such
as frequent micturition, varicose veins, neuralgia in legs and back, in-
digestion, difficult respiration, or hydronephrosis.

Uterine Polypus is another cause of irregular haemorrhage. They
are of three kinds. The most common forms are fibroid polypi and mucous
polypi. Placental and fibrinous polypi occur, the first after labour or
abortion, arising from retained portions of the placenta, the second from
the stump of a growth previously removed.

When very small, polypi can be made out with certainty only by dilating
the OS and exploring the interior. Later on, examination with the speculum
may reveal the polypus hanging from the os into the vagina. After a
time it may slough, and cause an offensive discharge.

444 DISEASES PECULIAR TO WOMEN [ §§ 825-827

§ 825. SuBiNVOHJTiON, or the non-return of the uterus to its normal
size, is a very frequent cause of menorrhagia after labour or abortion.
After a confinement the uterus begins to diminish in size, and at the
end of about two months, resumes its normal length of 2J inches. In
cases of subinvolution we find (1) on vaginal examination that the uterus
is enlarged ; (2) it tends in most cases to be retroverted and lower than
normal ; (3) the patient generally complains of backache, bearing-down
pain, and leucorrhoea ; and (4) lassitude, weakness, and general malaise
are usually present.

The Causes of subinvolution are important : (1) Getting up too soon
after childbirth is probably the reason why this condition occurs so fre-
quently among the poor ; (2) retained membranes or portions of placenta ;
(3) pelvic inflammation ; (4) delayed labour or over-distension of the
uterus ; and (5) the practice of not suckling the infant, account for this
not infrequent condition, and therefore it is more often met with in those
who have had numerous and rapid pregnancies.

§ 826. The Menopause, or climacteric, is the epoch at which the sexual
activity of the female imdergoes involution, when the menses, which are
the sign of that activity, cease. This may take place in three ways :
(a) They may cease gradually, and more or less irregularly ; (6) quite
suddenly; (c) they may be attended by a series of haemorrhages. The
last method, which is quite as frequent as either of the other two, is the
one with which we are now concerned.

The existence of this cause of menorrhagia or metrorrhagia can only
be recognised by the attendant phenomena. (1) The age of the patient
varies considerably between thirty-five and fifty-five, the average being
about forty-five. (2) The occurrence of " flush storms," which consist
of a hot stage, a cold stage, with or without shivering, and sometimes a
stage of perspiration. (3) Other nervous phenomena which may occur
at this time are extremely varied. There is generally an irritability and
restlessness, and generally also a marked tendency to depression of spirits,
causing the patient to burst into tears at the slightest provocation. This
may amount to definite melancholia, especially when there is mental
heredity. Sexual perversions, with a marked tendency to excess of all
kinds, are apt to occur. (4) While fibroids and other gross lesions some-
times undergo involution at this epoch, carcinoma, if there be a pre-
disposition, may make its appearance, and the case should be carefully
watched from this point of view.

§ 807. Malignant Disease of the uterus is clinically met with in four
forms : (a) Cancer of the cervix, chiefly met with in multiparse, between
the ages of twenty-five and seventy; (f>) cancer of the body, which is
chiefly met with in nuUipareB, between the ages of fifty and sixty;
(c) sarcoma of the uterus, which is rare, unless we include under that term
certain fibroids which appear to take on the malignant features of spindle-
celled or large round-celled sarcoma ; and {d) deciduoma malignum, a
very rare form following parturition.

§828] MALIGNANT DISEASE OF THE UTERUS 446

The symptoms differ in the first three varieties, (a) Cancer op the
Cervix usually nms a somewhat rapid course. (1) On digital examina-
tion the OS has a hard, friable, granular feel, which is so characteristic
that this feature and the blood-stained discharge upon the finger are alone,
in experienced hands, sufficient to diagnose the disease. (2) In a later
stage examination reveals a mushroom-like growth ("cauliflower ex-
crescence ") hanging down into the vagina, readily breaking down and
readily bleeding. It has a tendency to spread to the vaginal wall, to the
utero-sacral ligaments, broad ligaments, and body of the uterus, leading
to a fixity of the uterus and hardness which is easily made out on palpa-
tion. (3) Metrorrhagia and menorihagia are presen . (4) In the intervals
between the marked haemorrhages there is a continuous leucorrhoea of
pinkish-brown colour, often with a very offensive odour. (5) Local pain
is usually a late symptom, but, like the wasting and the cachexia, is sure
to supervene sooner or later.

(6) Cancer op the Body of the uterus is chiefly met with in nulliparae
over fifty years of age. Bleeding occurs at a later stage than in cancer
of the cervix. The symptoms are : (1) Metrorrhagia, and in the intervals
pinkish brain-like matter is discharged ; (2) on bimanual examination
the uterus is found to be enlarged. (3) If the passage of a sound is
attempted, considerable haemorrhage may take place. It should not be
used in cases with much bleeding and offensive discharge. (4) Later
on, as the disease extends to the broad ligaments, the uterus becomes
fixed ; this fixity to the educated finger is very characteristic of the disease.
(5) The cachexia and other general symptoms resemble those of cancer
elsewhere. The diagnosis from senile endometritis or a degenerating
fibroid can be made only by microscopic examination of the discharge
or a scraping taken for the purpose.

(c) Sarcobca of the Uterus is a relatively rare condition. Its symptoms do not
differ materially from those of uterine fibroid, except in the rapidity with which the
case progresses, and the liability to deposits elsewhere.

f 828. Bztra-nterine Pregnancy (or Foetation) may become manifest by monor-
rhagia, metrorrhagia, or amenorrhcea. The term is applied to the condition where
pregnancy takes place outside the uterus, generally in the Fallopian tube. The tube
usually ruptures at the second or third month after fertilisation, either into the broad
ligament (extra-peritoneally) or into the peritoneal cavity.

Symptoms. — (I) In many oases paroxysmal pains are experienced in one iliac fossa ;
(2) in about 70 per cent, of the cases there is a history of amenorrhcea for some weeks
or a month over time, followed in most cases by a history of irregular haemorrhages
from the uterus. A membrane or oast may be discharged from the interior of the
uterus at the same time. (3) Other symptoms of early pregnancy, such as morning
sickness, are but rarely present. (4) On bimanual examination a swelling is found
in the fornix, and the cervix is soft as in early pregnancy. In most oases, however,
none of the above symptoms may be noticed by the patient, and advice may not be
sought until the time of rupture of the tube, when the patient consults us for severe
pain and hemorrhage. Extra-peritoneal rupture is attended and followed by the
symptoms of pelvic hematocele ; intra-peritoneal rupture by the s3rmptoms of per-
forative peritonitis (f 169). If the rupture takes place about the fourth week the
shock is not so severe, and the hsematocele often remains extra-peritoneal. The
prognosis and treatment are discussed under H»matooele (§ 334).

446 DISEASES PECULIAR TO WOMEN [ f S28

The Prognosis of Hasmorrhage depends upon the cause in operation.
Uterine bleeding of itself is not fatal to life, but some fonns are very in-
tractable, and lead to considerable ansemia, debility, discomfort, and
inability to fulfil the duties of life. (1) The undue bleeding at the meno-
pause and of SUBINVOLUTION tends to spontaneous recovery, and that
which is due to coNSTiruTiONAL conditions is usually amenable to treat-
ment; so also, in many cases, is that due to pelvio inflammation.
(2) ENDOBfETRms is perhaps one of the most intractable of the causes,
though this also is remediable by local treatment. (3) The prognosis
in a case of fibroid tumour depends very much upon its positicm. The
submucous varieties (and mucous polypi, § 324) are readily treated, but
if neglected these may slough, and produce death by exhaustion and
septic intoxication. The subserous form may give but little trouble
for a great many years, and then chiefly by pressure symptoms. The
interstitial form is the most serious, and if there be much loss of blood and
consequent prostration the patient can only live a life of invalidism.
When of large size these tumours are very difficult to treat. Fibroids,
even if occurring near the menopause, should be treated surgically, because
they rarely spontaneously disappear. If the bleeding is not yielding to
styptics, removal of the tumour should be performed unless the patient's
general condition is prohibitive. Curettage is not permissible. X-ray
treatment is being tried with some success in cases which refuse opera-
tion. (4) Cancer is the most serious of all the causes of haemorrhage.
Cancer of the body of the uterus is not so grave as cancer of the cervix.
The chance of recovery depends upon the diagnosis of the disease and its
treatment surgically cU an early stage. If cancer of the cervix is discovered
before it has spread to the parts around, or if cancer of the body is taken
in hand while the uterus is still freely movable, operation o£Eers a fair
prospect of recovery. The prognosis of extra-uterine pregnancy is
discussed in § 334.

Treatment of Hcetnorrhage, — (a) Symptomatic, in all forms. To relieve
the h»morrhage calcium chloride in large doses (20 grains or more) is
most useful, as it promotes the coagulability of the blood. Ergot, adrenalin,
dilute sulphuric acid, tinctura hydrastis, tinctura hamamelidis, stjrptol,
tonics, chloride of iron, quinine, nux vomica, are all useful. 1 c.c. of a
20 per cent, solution of pituitary extract may be injected intramuscularly
or adrenalin applied locally in severe cases. If the haemorrhage is alarming
and plugging the vagina has been tried, the uterus must be plugged after
dilating the cervix. (6) Remedial treatment is directed to the cause,
and must be adopted in addition to the foregoing, (c) In all cases general
measures are required — the food must be nourishing, exercise must
\ye avoided near the period, and the patient must rest in bed while the
flow is profuse. While strong purgatives on the one hand must be avoided,
it is extremely important, on the other hand, to avoid constipation. For
the menorrhagia of the menopause bromides and calcium chloride are the
best remedies, and these also relieve the attendant discomforts.

§ 829 ] AMENORRHCEA 447

§ 329. Amen(»rhoea is that condition in which the catamenia are either
deficient or absent. The term primary amenorrhoea is applied to the
condition in which menstruation has never occurred, as in rare cases where
there is a congenital absence of the organs concerned in the function, and
also in cases of infantile uterus and undeveloped ovaries. Apparent
amenorrhoea is that form in which there is a feeling of fulness in the breasts
and abdomen every month, but the menstrual flow is retained behind an
imperforate hymen, an occluded os or vagina. In secondary amenorrhoea,
the flow, after having been once established, ceases or becomes deficient
for a time. Physiological amenorrhoea is the cessation of the menses
which occurs in pregnancy, a fact which must always be borne in mind
even amongst the most irreproachable patients.

In Pregnancy, the physiological cause of amenorrhoea, the General
Symptoms are as follows : (1) Morning sickness is usually one of the earliest,
coming on about the first or second, and ceasing at the fourth month ;
(2) the mammse present a dark areola around the nipple, they become
enlarged and after the third month contain milk. The Local Signs are :
(1) On digital examination there is a softness of the os which is unmistak-
able to the educated finger ; (2) a gradual increase in the bulk of the uterus
is early apparent. These are the earlier symptoms. About the third
or fourth month we have a series of unmistakable signs — ^viz., (3) about
the eighteenth week foetal movements can be felt by the physician, and
(4) the foetal heart-sounds (at the rate of 120 to 150 a minute) can be
heard on auscultation, usually midway between the umbilicus and left
anteriar superior spine ; and (5) ballottement can be made out about the
fifth or sixth month.

The Cai^es of secondary amenorrhoea may be divided into con-
stitutional and local causes, (a) Constitutional causes are by far the
most frequent, especially anaemia, or chlorosis, and phthisis. It also
occurs after severe illnesses, on account of some great grief (mental shock),
and during prolonged lactation, (h) The most important of the local
causes is perhaps an ovarian tumour, in which the state of the catamenia
varies, but the flow is often absent or irregular. Other causes are a
chill during menstruation, inflammatory conditions in the pelvis,
superinvolution of the uterus, and extra-uterine foetation.

Treatment in constitutional causes consists in plenty of fresh air, exercise,
good food, and general healthy living combined with iron tonics. Warm
baths, especially warm hip-baths at the expected time, are useful. It
is very important to keep the bowels regularly acting, and the old-
fashioned remedy of the aloes and iron pill is most beneficial. Per-
manganate of potash in 2-grain pills has been recommended. It is always
advisable to adopt the tonic treatment in young unmarried girls, and it
is only after these have failed that local causes ^ould be suspected, or at
any rate locally investigated. Pituitary extract is very useful in some
cases, apparently stimulating the ovaries.

448 DISEASES PECULIAR TO WOMEN [ §§ 8S0, 8S1

Sudden Suppression of the catamenia is a form of amenorrhoea which requires
special treatment. The flow has probably come on normally, and then suddenly
ceased on the second or third day, and the patient suffers a good deal of general
discomfort. In such cases the patient should put her feet in hot water or a mustard
bath, or sit in a warm hip-bath, and then should get into a thoroughly warm bed
with hot bottles and take hot drinks. Subsequently saline purgatives in constant
small doses, and general attention to the health are indicated. When the time of
the expected period again comes round, the procedure just mentioned should be
adopted.

§ 880. Pelvic Pain. — Pain in and about the pelvia is one of the com-
monest symptoms of disorder of the female reproductive organs. " Bear-
ing down " is often spoken of ; and " backache " or paili over the sacrum
is so constant a feature of uterine disorders that it has come to have that
association in the minds of the laity. The position and character of pelvic
pain vary with the different maladies, but its degree is largely influenced
by the temperament of the patient. Reference has already been made
to painful menstrual periods (dysmenorrhoea), but the causes of a con-
tinuous pain (without reference to the menstrual period), such as that
now in question, may be conveniently grouped into (a) those pains which
come on more or less suddenly (acute conditions), and (b) those which
come on more or less insidiously (chronic conditions). It must, however,
be remembered that no hard and fast rule can be laid down in this respect.

(a) The pelvic pain came on acutely and recently ; it is accompanied by
more or less coNSTrruriONAL disturbance — peri- or para-bcbtritis,

INFLAMMATION of the UTERINE APPENDAGES, PELVIC HJBMATOOELE, ACUTE

CYSTiris, or some other inflammatory coNDmoN within the pelvis,
may be suspected, and the reader should first turn to § 331.

If the PAIN has corns on very suddenly with faintness and nausea,
turn first to pelvic hematocele, § 334 \ if it be accompanied by metror-
rhagia, it is suggestive of miscarriage, or extra-uterine F(etation(§328).

§ 881. Perimetritis (Pelvic Peritonilis), which is one of the most frequent
causes of pain, is an inflammatory condition affecting the peritoneal
surfaces around the uterus and its appendages. Exudation may be
present, and in chronic cases the adhesions lead to a matting together
of the pelvic viscera.

The Symptoms of Acute PERiMETRms are (1) acute pain across the
lower part of the abdomen ; (2) the abdomen is distended and tender to
palpation, and a suprapubic mass of matted intestine may be felt. The
patient lies on the back with legs drawn up ; (3) on examination, the
vagina is found to be extremely tender ; (4) on vaginal examination forty-
eight hours later the uterus is foimd to be fixed, with a certain amount
of exudation surrounding it, which may be so great as to push the uterus
forwards; (5) the general symptoms consist of high fever and quick
pulse, with vomiting.

In Chronic Perimetritis (1) the pain is felt across the lower part
of the abdomen, and is often greater on one side ; backache is usually
present. The pain is constant, of a bearing down character, worse at
the menstrual period; (2) dysmenorrhoea and sometimes symptoms of

I «S8 ] PARAMETBITia 449

endoiuetritis accompany it ; (3) on examination the mobility of the uterus
is found to be diminished, and thickenings, chiefly in the posterior fomixy
can be felt behind the uterus, in which situation a kind of " roof " to the
vagina exists. (4) The general symptoms consist of an inability to stand
or to walk for any length of time ; and in severe cases chronic invalidism
with mental depression or hysteria results.

Causes, — (1) Inflammation of the vagina or endometrium, especially
that due to gonorrhoea, extending up by way of the Fallopian tubes b
a common cause of pelvic peritonitis. After confinement or abortion acute
pelvic peritonitis is often caused by extension of inflammation. (2) Men-
strual regurgitation, or a chill during the menstrual period, may give rise to
pelvic peritonitis. (3) Chronic pelvic peritonitis may be set up^by ovarian
tumours, fibroids, cancer, or tubercle. Prognosis and TreatmefU below.

§ 882. Parametritis (Pelvic Cellulitis), another cause of pelvic pain, is
an inflammation originating in the connective tissue of the pelvis adjacent
to the uterus. This also may be acute or chronic.

The S3rmptoms of Acute Parambtbitis are (1) pain across the lower
part of the abdomen, usually shooting down one leg; and the patient
usually lies with one leg drawn up to rdieve the pain. In a few cases no
pain is complained of at first. (2) On examination swelling and tender-
ness are made out in one of the lateral fomioes, or one postero-lateral
quarter of the pelvis. No swelling is felt in Douglas' pouch (the posterior
fornix) unless pelvic peritonitis is also present. (3) The general symptoms
are those of fever, generally of a hectic type, with quick pulse ; in those
cases where no pain is felt attention is drawn to the condition by the rise
of the patient's temperature.

In Chronic PARAMETRms there are backache, dysmenorrhoea, fre-
quently uterine displacement (due to the contraction of the inflammatory
tissue), and symptoms of endometritis. When it results in suppuration
or *' phlegmon," the pus may make its way in various directions upwards
or downwards.

Causes, — Parametritis usually follows labour or abortion in which
injury to the cervix, vagina, or perineum has occurred, with consequent
entrance of septic matter. Thus, injury by septic instruments may also
produce it, and clumsy attempts at procuring abortion form a not infrequent
source. Apart from these, parametritis is practically unknown. The
serious results which may be produced by septic absorption and the
prompt effect of thorough asepsis are well illustrated in Fig. 90.

Course and Prognosis, — (a) In acute perimetrUiSy the acute symptoms
should subside in a week ; if widespread adhesions are present, part of
the exudation will be absorbed, and part will remain, giving rise to the
sjrmptoms of chronic perimetritis. Chronic perimetritis is often in-
curable. The prognosis will depend (i.) upon the extent of the inflam-
mation, and (ii.) its cause. If it is the sequel to an acute attack with
widespread adhesions the patient will probably have chronic pelvic pain
and dysmenorrhoea all her life. If due to extension from a diseased

460 DISEASES PECVLlAH TO WOMKN H**i

organ, the patieut will be subject to relapses with acute pain alter any
imprudence in the way of chills or over-exertion.

(6) In acute faTametntis, il treated properly, the fever should subside
in a week, and the exudation will probably be absorbed in three weeks.
If the fever continues for four or five weeks pus has formed, and the
patient wUI be invalided until the pus finds an exit (which may not be
for months). The swelling felt in one lateral fornix becomes larger,
pushing the uterus to one side, and later on a firm lump, which may
extend to the iliac fossa, is felt along Poupart's ligament. The pus may
point in the iliac fossa or follow the line of the vessels into Scarpa's
triangle ; or it may burst into the vagina, bladder, rectum, or peritoneal

in ihowiQg effect ol iDtn-ut
isccDtly oonHned ; wpUctemla •Mmel to be tbreitenlng, but miter tboioughljr muhliii oi
the iiilcrlor of the ateru all the aymptoins aabilded.

cavity. In chronic pelvic ceUulUia adhesions and fibrous tissue are formed
rather than pus. These may be absorbed in time, but anteflexion or
version of the uterus is s common result of the contraction of the utero-
sacral ligaments which occurs.

Treatment. — Aaite peri- and para-metritis must be treated by (i.) abso-
lute rest in bed ; (ii.) hot fomentations, turpentine stupes to the abdomen,
hot vaginal douches and vaginal ichthyo] plugs; (ili.) saline purges;
(iv.) morphia, it necessary, to alleviate the pain. In some cases
(v.) vaccines or serum should be tried. Watch for the formation of abscess,
and open it if possible by the v^ina. PreveiUive treatment consists
especially (1) in cleanliness of the hands of the nurse or doctor who
attends a oaw of labour or abortion, and (2) in the curing of a vaginitis

{ 888 ] INFLAMMATION OF THE UTERINE APPENDAGES 451

or an endometritis before it can extend up to the Fallopian tubes. The
treatment of chronic peri- and para-metritis consists of (1) the admin-
istration of hot vaginal douches (up to 120° F.) daily, each douche
lasting ten minutes ; (2) ichthyol tampons ; (3) treating the pain,
dysmenorrhoea, menorrhagia, and other symptoms as described under
those conditions. Cold or damp and undue exertion in walking or
standing must be avoided ; and a certain daily interval of rest in the
recumbent position should be ordered. K symptoms persist, surgical
advice should be sought. Durmg and after convalescence it is important
to avoid constipation. When suppuration has occurred, the pus must be
evacuated by free incision, preferably per vaginam. Vaccines may be very
useful.

§ 333. Influnmation of the Uterine Appendages (viz., Ovaritis and
Salpingitis) may also be a cause of pelvic pain.

OvARms is inflammation of the ovary, and should be distinguished from ovarian
neuralgia. The Symptoms of ovaritis are so frequently accompanied by those of
perimetritis that it is difficult to differentiate them. Indeed, acute ovaritis is found
solely with acute peri- or para- metritis (q-v.). Chronic ovaritis may bo recognised
by (1) severe pain at the pelvic brim, extending down the thigh of the affected side ;
(2) pain increased by any pressure on the pelvic viscera {e.g., by much standing, con-
stipation, or flatus in fhe abdomen, and in severe cases by sitting) ; (3) menorrhagia
and dysmenorrhoea, because endometritis so often accompanies ovaritis ; and
(4) dysparcunia. (5) The ovary is usually prolapsed, and therefore, per vaginam,
a swelling, the size of a walnut, is found at the site of the ovary, to one side of or behind
the uterus, acutely tender to touch, which caus:;s a sickening pain. General symp-
toms, referable for the most part to the nervous system, very frequently supervene.
The Causes of (1) acute ovaritis are sepsis after labour, abortion, or surgical opera-
tion ; (2) chronic ovaritis may be duo to the samo causes as perimetritis, to alcoholism,
to certain fevers {e.g., mumps), or to the suppression of menstruation by a chill.

Salpingitis (inflammation of the Fallopian tubes) occurs in three forms, hydro-,
pyo-, and haemato-salpinx. (i.) When the fimbriated end of the tube is closed by
adhesions, the exudation within, unable to escape, tends to accumulate in the tube
instead of escaping by the uterine opening (hydrosalpinx) ; (ii.) when the tubes are
tilled with pus (tuberculous, gonorrhoeal, or septic) the condition is named pyosalpinx ;
(iii.) when the tubes are filled with blood, haematosalpinx.

The Symptoms of salpingitis are (1) jjain across the lower part of the abdomen,
usually greater on one side, often shooting down one leg ; (2) on examination a sausage-
shaped swelling is found, usually double, running from the lateral fomices to Douglas'
pouch ; (3) as perimetritis usually accompanies it, the uterus is less mobile than
normal ; (4) dysmenorrhoea and menorrhagia are usually marked. (5) As regards
the general symptoms — in hydrosalpinx there may bo none, but pyosalpinx is accom-
panied by fever. In a pyosalpinx of sudden onset (gonorrhoeal), the fever may
be very high. Causes. — (1) Acute salpingitis is due to septic or to gonorrhoeal in-
fection extending upwards ; (2) chronic pyosalpinx, which is the commonest form of
salpingitis in young single women, is usually due to tubercle, generally secondary to
tubercle of the lungs or elsewhere. It may take an acute form. (3) A chronic or
subcMJute vaginitis or endometritis extending upwards may result in salpingitis.
Thus/ sepsis or gonorrhoea following childbirth, and the use of dirty instrumente, are
common causes (see Vaginitis and Endometritis for other causes). (4) Hsemato-
salpinx is due usually to a ruptured extra-uterine pregnancy.

The Prognosis of ovaritis depends on the extent of the inflammation around. If
there is much matting the case is really one of perimetritis. If the inflammation is
confined to the ovary the prognosis is favourable, provided the cause be removable
and the patient is not of a neurotic constitution. In salpingitis sterility may result
from adhesions closing the fimbriated extremity (though this cannot be diagnosed

452 DISEASES PECULIAR TO WOMEN [ § 834

with certainty). Pyosalpinx is daugerouB to life, as it may at any time burst into
the peritoneum. Tuberculous salpingitis is very chronic, and less painful than tho
other forms. In all forms there is a tendency to relapse, and to peritonitis by ex-
tension rather than to spontaneous cure.

Treatment, — ^Acute and chronic ovaritis are treated like perimetritis {q.v.), together
with hot applications to the hypogastrium when the pain is severe. Blisters and
odine applications over the iliac region have been recommended. If the suffering
is severe, the ovaries may require to bo removed. Constitutional treatment must
not be neglected — bromides, potassium iodide, and tincture of belladonna are bene-
ticial. In acute salpingitis, when a pyosalpinx has resulted and the condition can
bo certainly diagnosed, laparotomy should be performed and the tube removed. In
other cases rest in bed with hot douches may tide over the acute stage. In chronic
salpingitis, rest, hot douches, and the ichthyol tampons may be tried for a period
of two years at least. If this treatment fail, it will probably be necessary to remove
the tubes.

§ 884. Pelvic HsBmatocele is an effusion of blood either into the peritoneal cavity
(intraperitoneal) or into the connective tissue of the broad ligament (extraperitoneal),
usually due to a ruptured tubal pregnancy (§ 328). Here there is a sudden onset of
(1) severe pain, starting in one iliac fossa and soon spreading over all the lower part
of the abdomen, accompanied by (2) faintness, perhaps unconsciousness, with
(3) nausea, and in some cases vomiting. (4) There may be some uterine haemorrhage,
with discharge of a cast of the interior of the uterus. (5) On examination, the uterus,
in the intraperitoneal variety of pelvic haematocele, is found pushed forwards behind
tho pubes, while in the extraperitoneal variety the swelling is smaller, and causes a
lateral displacement of the uterus as in pelvic cellulitis. The intraperitoneal variety,
if large, forms a lump which can bo felt, on bimanual examination, both in Douglas*
pouch and above the pubes, and the abdomen is tender and distended. After forty-
eight hours, adhesions form and the uterus is fixed, and other signs of pelvic peritonitis
may then ensue. The temperature begins to rise in twenty-four hours after the
onset of pain — that is to say, when the i>elvic peritonitis commences.

Diagnosis. — If the bleeding is (a) intraixjritoneal, tho haemorrhage is rapid and
excessive ; (6) if extraperitoneal, it is usually slow and limited in amount and tends to
become encysted, (a) In the former, in addition to the symptoms of abdominal pain
with collapse, there are the symptoms caused by haemorrhage, viz., restlessness and
air- hunger. The diagnosis from a raptured viscus (§ 1U9) is very difficult at first.
(6) When there is a smaller amount of bleeding, there may be acute pain and collapse,
as above, but the symptoms may subside after a few hours, and attacks of pain may
recur at intervals for days. The local signs resemble pelvic cdlulitis, from which it
may be diagnosed by a history pointing to extra-uterine pregnancy, and by the fact
that pyrexia is absent at the onset, and there is pallor and a pulse of low tonsion.

Prognosis, — If haemorrhage be largo, death has been known to occur in about an
hour. In smaller haomorrhagos adhesions due to pelvic i>eritonitis or cellulitis follow,
and the exudation may be (i.) entirely absorbed, or (ii.) may go on to suppuration
with a daogor of general i)eritonitis. VVheu due to extra-uterine pregnancy, an extra-
l^eritoneal is not so immediately serious as an intraperitoneal hsomorrhago. Secondary
rupture may occur into the peritoneum. In rare cases the foetus may live till full time,
when the patient goes through a spurious labour, after which the placenta becomes
absorbed and the foetus mummified, causing no symptoms.
Treatment is operative, except in the eneysted variety, when operation is not so urgent.

(6) The pain is of a ohronic character, is of considerable duration, and is
UNATTENDED by PYREXIA. Almost any of the different diseases mentioned
in this chapter may be suspected. Examination may reveal endo-
metritis, ENDOCERVICmS, CHRONIC PERI- Or PARA-METRITIS, Or a

UTERINE DISPLACEMENT ; or careful bimanual examination may reveal

a PROLAPSED OVARY Or au INFLAMED TUBE. UtERINE DISPLACEMENTS

and Pelvic Tumours alone remain to be considered. Prolapse of the
uterus is a cause of dragging pain, especially in its early stages.

§ 886 ] UTEBINE DISPLACEMENTS 463

§ 885. uterine Displacements. — The normal position of the uterus is
one of anteversion, with slight anterior flexion. The uterus undergoes
physiological displacements according to the fulness of the bladder and
rectum. In itself a displacement leads to no symptom ; the symptoms
so often associated with displacement are due in the majority of cases to
the inflammatory processes in or near the uterus which have caused the
displacement. Tumours, etc., in the pelvis may cause Lateral Dis-
placements of the uterus.

Forward Dlsplacements (Anteflexion). — On examination bimanually
the 03 is found to he high up, and the fimdus is felt unduly far forward.
The sound passes with some difficulty. In single women a stenosis of
the OS or an elongated cervix may accompany a forward displacement
of congenital origin. As above stated, Symptoms may be entirely absent,
and attention is first drawn to the condition when other mischief, such as
pelvic inflammation, endometritis, parametritis, or a history of dysmenor-
rhoea, sterility, or constantly recurring abortions, is present.

Causes. — (1) A congeni tally ill-developed uterus is often displaced
forwards. A forward displacement is diagnosed to be pathological in
origin, as distinct from physiological, by the lessened mobility of the
uterus, and the pain set up on attempting to move it. Forward dis-
placements are found in association with (2) pelvic peritonitic adhesions,
and (3) cellulitis affecting chiefly the utero-sacral ligaments.

Prognosis. — Anteflexion is a frequent concomitant of sterility. Its
treatment is extremely troublesome, but if consistently and carefully
carried out a radical cure is certainly to be expected unless the con-
dition is due to a considerable degree of pelvic peritonitis or cellulitis, when
the prognosis depends upon the removability of these conditions.

Treatment. — Treatment must be directed to any pelvic peritonitis or
cellulitis present (q.v.). Ichthyol tampons and hot douches with purga-
tive treatment will work wonders in the slighter forms. Massage is highly
recommended where the anteflexion is due to the contraction of the
utero-sacral ligaments. Dilatation of the cervix has aided some cases.

Backward Uterine Displacements consist of retroversion aud retro-
flexion. In a backward displacement there is also a certain degree of
descent of the uterus. Retro-displacements in themselves cause no
symptoms ; sometimes they are congenital. On examination the finger
detects the forward displacement of the cervix, which is usually somewhat
lower than normal. The uterus is not palpable in the anterior fornix,
whereas a lump is felt in the posterior fornix, which is found to be the
uterus because it is movable with the cervix, and can be felt to be con-
tinuous with the cervix.

Symptoms arise when pelvic adhesions are piesent, or when the dis-
placed organ interferes with other oigans in the vicinity. In such con-
ditions, a re trove rted uterus gives rise to (I) pain in the back and the
lower part of the abdomen of a bearing down, dull, aching character ;
(2) dysmenorrhoea and menorrhagia ; (3) constipation and painful defsBca-

454 DISEASES PECULIAR TO WOMEN [ §§ SSS, 887

tion. (4) If pregnancy occur, the sickness of the early months is excessive,
and after the fourth month theie may be retention of the urine, with drib-
bling, and subsequently sloughing cystitis.

Diagnosis, — The diagnosis of a backward displacement is not difficult,
but the diagnosis of the cause may be obscure. It is important first of
all to determine whether the uterus is freely movable or not, as the
prognosis and treatment differ.

Causes. — ^The causes of backward displacement are (i.) congenital ;
(ii.) the dragging of adhesions consequent on pelvic peritonitis ; (iii.) changes
in the uterine tissues, such as subinvolution, or tumours in the walls ;
(iv.) relaxation of the ligaments, as after pregnancy ; (v) sudden fall or
strain ; and in a few cases (vi.) a habitually over-distended bladder.
Several of these causes may act in combination ; thus, subiavolution
together with a relaxation of the ligaments cause a retroversion with a
certain amount of downward displacement of the uterus, as pointed out
in Prolapse.

. Prognosis. — (I) So long as the uterus is freely movable and not enlarged,
there may be no symptoms until pregnancy occurs. Most often, perhaps,
constantly recurriDg abortions take place. (2) In time retrodisplacements
are apt to lead to congestion and enlargement of the uterine body, with
endometritis "erosions," and prolapse of the ovaries. Adhesions may
ensue with chronic inflammation of the tubes and ovaries. (3) Where
the uterus is boimd down by adhesions, there is a condition which, according
to Playfair, is " not fatal, but tends to life-long discomfort."

Treatment. — (1) Where the uterus is freely movable, replace it by
bimanual manipulation, or, if necessary, with the aid of the sound. A
Hodge's pessary should be worn so long as the uterus gives any sign of
returning to the backward displacement. Where there is pregnancy and
the uterus cannot be replaced, even under chloroform, it may be necessary
to terminate the pregnancy. If adhesions hold the fundus down, they
must be divided. In the majority of cases in which pregnancy occurs in
a retroverted uterus, spontaneous rectification of the fundus occurs
between the third and fourth month. Pelvic inflammation must be
treated.

§ 886. The following are some of the more important Pelvic Tamoan and Vaginal
Swellingi : (a) Internal tumowra — (1) uterine fibroid ; (2) cervical or uterine polypus ;
(3) cervical or uterine cancer ; (4) retroverted uterus ; (6) pelvic cellulitis ; (6) ovarian
tumour ; (7) pyosalpinx ; (8) appendix abscess ; (9) pelvic hsematocele ; (10) hydatid
of the pelvis, (h) External swdlings or, swellings about the vulva may be due to
(1) prolapse of the uterus ; (2) inversion of the uterus ; (3) prolapse of the vaginal
walb (cystocele and rectocele) ; (4) cysts or tumours of the vaginal wall — e.g., of
Bartholin's gland ; 5) uterine polypus with a long pedicle ; (6) local conditions of the
vulva, such as abscess, hsematoma. or labial thrombosis (§ 319) ; (7) cysts of the vaginal
wall are usually found on the anterior wall, about the size of an egg and painless ;
(8) hernia.

Most of these various conditions have already been fully referred to, but three
conditions which may appear as external swellings remain to bo described — Prolapse
OF THE Vaginal Walls, Prolapsb of the Uterus, and Inversion of the Uterus.

§ 887. Prolapse of the Vaginal Walls is very common in multiparse, especially of
the anterior wall. It is then named cystocele, because of its close connection with

§ 888 ] PROLAPSE OF THE UTERUS 46ff

the bladder ; indeed, the anterior vaginal wall may draw down the posterior wall of the
bladder along with it. Prolapee of the posterior wall may ooour, and when the rectum
ifl prolapsed also, is named rectocele. But, as the rectum is not so intimately attached
to the posterior vaginal wall, a prolapse of that wall is not usually a rectocele. The
only symptom in addition to the swelling may be difficulty in passing water until tho
prolapsed part is pushed up. The diagnosis from a cyst of the vaginal wall is made
by passing a sound per urethram and with one finger in the vagina, feeling the point
of the instrument in the bladder. The chief predisposing cause of prolapse of tho
vaginal wall is a ruptured perineum.

For the TreatmefU of the two conditions, see below.

§ 888. ProUpte of the Utenu is its displacement downwards. Three degrees of
displacement are described : (i.) The organ may occupy a position somewhat lower
tlum normal ; (ii.) it may have pertly or entirely passed through the vaginal orifice
(procidentia) ; and (iii.) in extreme procidentia it lies entirely outside the vulva, the
body lying in the inverted vaginal wall.

In slighter cases the vaginal wall is seen coming down on asking the patient to strain.
In severer degrees the cervix can be seen and the body of the uterus and the ovaries
can be felt. The other symptoms of prolapse of the uterus are : (i.) The uterus is
enlarged, the cervix is frequently hypertrophied, there may be accompanying endo-
metritis or endocervicitis ; (ii.) there is difficulty in passing water till the prolapsed
organ is pushed up ; (iii.) sometimes there is a weight or a bearing-down feeling in
the pelvis, but more often no pain is complained of, and only the discomfort of the
lump during walking and sitting is remarked. In the early stages, on the other
hand, backache may be a prominent feature, (iv.) The uterus is usually retroflexed.
(v.) Leucorrhoea is usually troublesome. Ulceration of the external parte is apt to
supervene on procidentia.

Causes. — (1) The predisposing causes of prolapse of the uterus, as in prolapse of
the vagina, are (i.) a ruptured perineum ; (ii.) a relaxed condition of the parts after
labour ; and (iii.) a laborious occupation which demands much muscular strain, such
as that of a washerwoman. The exciting causes are (i.) increased intra-abdominal
pressure, such as occurs with muscular work and tight lacing ; (ii.) the increased
weight of the uterus in cases of subinvolution or tumour of the wall.

Treatment. — Preventive treatment is highly important. Every woman must rest
sufficiently long after labour to ensure involution of the uterus. All i>erineal lacera-
tions must be repaired as soon as possible. The uterus must be replaced by pushing
up first the posterior vaginal wall, then the uterus, then the anterior vaginal wall.
Then rest in bed, with tonics and general massage, may cure the condition. In other
cases tampons of ichthyol and glycerine are inserted and changed every two or three
days ; when inflammation or undue swelling has been reduced by these means, the
insertion of a ring pessary is sufficient. In cases where procidentia has occurred a
cup and stem pessary may be necessary. After the menopause prolapse may be
difficult to cure, because a pessary in the vagina of old people is so apt to cause ulcera-
tion. In some conditions surgical interference is called for.

Invenion of the Utemi. — Sudden inversion of the uterus may occur in the third
stage of labour, when the fundus is relaxed, but here we are concerned only with the
chronic form of inversion, a very rare condition. It may be the sequel to acute
inversion if the patient survive the shock, or it may bo due to the dragging of a
tumour. The fundus alone may be inverted through the os, or tho whole uterus
may be inverted. (1) The swelling is red, bleeds readily, and is tender. (2) The
sound cannot be passed the normal distance, if at all. (3) Bimanually the fundus
is found absent ; and if a sound is placed in the bladder in the middle line and the
finger in the rectum these can be made to meet without any uterus being felt.
(4) There may be symptoms of bearing-down, menorrhagia, and leucorrhoea. The
Diagnosis may have to be made from fibroid polypi ; in which the fundus is not absent
from its usual position. The orifices of the Fallopian tubes can sometimes be dis-
tinguished.

Prognosis. — ^There is no tendency to spontaneous cure. Death may occur after
a long period of suffering and an»mia, from exhaustion or septio«emia. The Treat'
ment is altogether operative, and we must refer the reader to a textbook on GynsDCology.

466 DISEASES PECULIAR TO WOMEN [ { 999

i 880. It is proposed to discuss briefly the causes of the following symptoms for
which the physician may be consulted : (a) Disordered Mictturitiok (Retention,
Unduly Frequent, Painful, or Difficult Micturition and Incontinence ; (b) Paintul
Dbfjegatiok ; (e) Pain ok SnnNO ; and (d) Dysparbukia.

(a) Dif ordered Miotnrition is dealt with more fully in kidney diseases (§§ 311 to
313) ; here only a few of those special to the female wfll be mentioned.

I. Retentiok of the Urikb. — The Causes peculiar to women are impacted fibroids,
malignant disease of the cervix involving the vagina, tumours of the vagina, a retro-
verted uterus (especially when about the fourth month of pregnancy), and other con-
ditions causing obstruction of the urinary passage consequent on pressure over the
mouth of the bladder. The condition is also found in reflex retention after opera-
tions on the perineum and in hysteria.

II. FREQUEirr Micturition may be produced in women by (i.) pressure on the
bladder from a tumour or an enlarged anteflexed uterus ; (ii.) a vascular carunde
of the urethra ; (iii.) acute C3rstiti8 ; (iv.) cystocele ; (v.) pelvic inflammation, especially
during the early stages ; (vi.) calculi and gravel ; and (vii.) various nervous conditions.

III. Paintul Micturition is found especially in connection with urethral caruncle,
cystitis, and in the early stages of pelvic inflammation or ovaritis.

rv. Ingontinencb of the Urine is found (i.) in vesico- vaginal or vesioo-uterine
fistula ; or (ii.) after dilatation of the urethra has been i>erformed — e,g., as a pre-
liminary to lithotrity.

V. Difficult Micturition is found (i.) after labour, when the parte are swollen
and bruised ; (ii.) with prolapse of the uterus, in which case the symptom is relieved
on pressing upwards the prolapsed parts ; (iii.) all causes of incomplete obstruction.

(S) Painful Defiecatton may be due to (i.) retroverted and retroflexed uterus,
especially when bound down by adhesions ; (ii.) an incarcerated retroverted pregnant
uterus ; (iii.) pelvic inflammation when acute ; (iv.) ovaritis ; (v.) prolapsed ovary ;
(vi.) coccydynia ; and (vii.) a fibroid or other uterine tumours pressing upon the rectum.

(e) Pain on Sitting and Ooocydyiiia are often associated with painful defecation
(1) The commoner external causes of painful sitting are (i.) a vascular carunde of the
urethra ; (ii.) vtdvitis and all other acute conditions of the vulva ; (iU.) haemorrhoids
or fissures of the anus. (2) The internal causes of painful sitting may depend upon
(i.) an increased pressure within the pdvis — e.g,, pdvic inflammation, or any tumour
within the pelvis ; (ii.) injury or inflammation affecting the sacro-soiatic and the
sacro-cocoygeal ligaments ; (iii.) a movable condition of the sacro-iliac joints after
parturition ; or (iv.) a rheumatic condition of the same joints, (v.) Dislocation,
inflammation, or " neuralgia ** of the coccyx is also a recognised cause of the con-
dition.

Diagnoeis. — ^The diagnosis of pelvic inflammation is treated of elsewhere. Newrdlgia
of the coccyx is known by the fact that the coccyx is sensitive to the touch. It may
be connected with constipation or disorder of the rectum. Injury of the sacro-sciatic
or sacro-coccygeal ligaments is known by: (L) the history of pain often dates from
childbirth, or from the injury which produced it ; (iL) pain is produced by pressure
on the ligaments, which tightens them ; and (ii.) there is an absence of swelling or
dislocation of the bone. Dislocation of the coccyx has no pain or tendemees, and is
known by the fact that the bone, in most conditions, is displaced backwards. When
the dislocation is found to be forward, it is much more painful, so that the patient
usually sits on one ischial tuberosity — i.e., sits sideways. In a motxible condition
of the joints there is a history of pregnancy with lameness towards the end of gestation,
and the patient complains of pain over the pubic bone. In slight cases it may bo
very difficult to diagnose. Bhewnatism is known by the absence of other local signs
and by the shifting character of the pain, and perhaps the fact that the patient has
other manifestations of rheumatism.

Prognosis and Treatment. — Vulvitis and pelvic inflammation are treated of else-
where. Inflammation and neuralgia of the coccyx are usually cured by laxatives,
hot baths, and sedative applications. Injury which has affected the ligaments may
also be cured by laxatives and hot baths, but the improvement is slower. Some
advise in extreme conditions the division of the ligaments. Dislocation of the coccyx,
if backward, may be a cause of no great inconvenience, but if recent may be reduced

§840] BACKACHE 457

at the time ; if of old standing it should be left alone. A forward dislocation, on the
other hand, is much more troublesome, and may require the removal of the coccyx.
A movable condition of the joints tends to recover spontaneously. It may b©
necessary to make the patient rest for a time, and afterwards to walk with a tight
bandage across the pelvis.

(d) Dyiparennia (painful coitus) may arise from a variety of causes. (1) The most
frequent is a functional spasm of the sphincter vaginae, associated perhaps with a
general neurotic state. In these circumstances the attempt to pass a speculum
will sometimes elicit the same spasm, but may also be a means of euro. (2) Various
other local conditions should be carefully looked for, such as a vascular caruncle
of tJie urethra, vulvitis, or vaginitis (see above). Fissures or small ulcers between
the folds of the parts, or hidden by the remnants of the hymen, are apt to be perennial
causes of discomfort, which will remain undiscovered from month to month and
perhaps year to year. (3) Ovaritis or a prolapsed ovary may produce considerable
pain on deep penetration. (4) Parametritis (especially when associated with endo-
cervioitis), perimetritis, and retention of foreign bodies, are also apt to become causes
of dyspareunia. (5) Masturbation in the female. (6) Finally there may be, though
this is relatively rare, a disproportion between the parties concerned.

Prognosis and Treatment, — ^The condition of dyspareunia is apt to lead to con-
siderable discomfort, not only to the individual, but to home life in general, and may
lead to far-reaching consequences ; and when at length the aid of the physician is
sought it behoves him to make his investigation with the greatest care, and express
his opinion with considerable tact. The first step is to make a very careful and
minute examination in a thoroughly good light and under the most favourable cir-
cumstances for a local investigation, in view of the minute causes which may underlie
the difficulty. The passage of a good-sized speculum will often cure vaginismus.
The local conditions referred to must be treated. Cocaine ointment and suppositories
and small doses of bromide may be tried. Childbirth frequently cures vaginismus
and many of the causes mentioned.

§ 340. Backache. — Pain in the back may accompany various chest
diseases ; for these see § 72. We are here concerned with the pain
in the lumbar region which is so frequently complained of, especially by
women. The symptom is dealt with in the chapter on diseases of women,
not because pelvic disease is always associated with backache, but because
pelvic troubles are perhaps the most common cause of the backache for
which the physician is consulted.

Physical Examination. — When the patient complains of backache, the
physician should make a thorough examination of the region over which
the pain is felt. For the adequate performance of this examination it
is essential that the patient should be stripped. If the clothes are removed
only so far as the waist, important physical phenomena may be over-
looked. Note first whether there is any curvature of the spine, displace-
ment, tumour, or redness. By palpation endeavour to make out the
presence and position of any tenderness or swelling. Examine next the
precise position of the pain ; whether it is unilateral or bilateral ; whether
it is accompanied by tenderness or not ; whether it is aggravated by the
movements of certain muscles or joints ; whether it radiates along the
course of any nerve. The presence or absence of muscular spasm should
be ascertained. Examine the sacro-iliac joint and the costo-vertebral
joints, and whether pressure over those joints elicits pain. An examination
should be made next of the viscera ; thus, percussion may reveal an
abnormal area of dulness over the kidney ; vaginal and rectal examinations

468 DISEASES PECULIAR TO WOMEN [ § 840

may reveal disorders in these regions. The urine must be examined ; it
may show signs of kidney disease. Failing light from these sources, an
X-ray examination should be made. The history of the onset of the
pain, and of the concomitant symptoms at the time of the onset may give
important clues in the diagnosis.

Causes of Backache. — (1) Backache occurs in many acute diseases, in
most of the acute specific fevers, notably small-pox and influenza, and its
cause is then recognSd by pyrexia and other syTptoms.

(2) Functional Causes. — In nervous individuals, whose general health
is below par, fatigue is usually evidenced by backache. It is frequently
met with after childbirth, after infectious diseases, and after operations.
This is by far the most frequent cause of backache, both in men and
women. It is relieved by rest, by suitable corsets, or other supports,
and tends to disappear as the general health improves.

(3) Lumbago is known by : (i.) a history of a sudden onset, usually
when stooping ; (ii.) the pain is increased by movement of the lumbar
muscles, and is relieved by local warmth ; (iii.) tender points may be elicited
in the fascia, near the origin and insertion of the muscles afiected.

(4) Curvature of the spine, whether it be due to Pott's disease or to
simple lateral curvature, is a cause of backache. The later stages of
Pott's disease (tuberculosis of the vertebiae) show an angular curvature,
and come under the notice chiefly of the surgeon. The early stages are
frequently overlooked, as no symptom may be present except pain. It
demands for its cure prolonged rest and general treatment as in other
forms of tuberculosis. The slighter forms of lateral curvature are a fre-
quent cause of backache in children and young women, especially on
standing. This cause of pain often fails to be diagnosed, especially in
the early stages, because of the neglect of the guardian or physician to
examine the spine with the patient stripped.

(6) Sacro-iliao disease is another common cause of backache. It is known by :
(i.) pain and tenderness over the joint is made out on palpation, or when the ilium
is pressed inwards by the physician ; (ii.) pain is elicited by flexing the thigh on the
abdomen while the leg is kept straight ; (iii.) the patient sometimes stands on one leg,
and may complain of pain passing down one sciatic nerve ; (iv.) there is usually
a history of strain. Strapping and fixation of the joint, with rest, relieve this form
of backache.

(6) Osteo-arthritis is known by : (i.) signs of the disease elsewhere ; (ii.) the pain
is made worse by coughing or sneezing ; (iii.) the pain usually radiates down t^e lumbar
or sciatic nerve.

(7) Backache may be due to disease connected with the kidneys, such as perine-
phric abscess, tumour, ston'^, and pyonephrosis. An examination of the urine may
first lead the physician to suspect the kidneys.

(8) Other abdominal tumours, such as retroperitoneal sarcoma, aneurysm, and
tumour of the spine, may be differentiated by the X-rays when visual and tactual
examination fails.

(9)^Qall-stones may rarely give rise to pain in the back before the pain works round
to its usual situation in front.

(10) Finally, spondylitis or inflammation of the vertebral joints may be mentioned
as a cause of backache sometimes following tjrphoid fever or sjrphilis. It is a condition
widely^recognised in America, although so far it has not received much attention in
this country.

CHAPTER XV

PYREXIA

MIGROBIC DISEASES,

When a patient is suffering from some general or constitutional derange-
ment, he complains of a vague " feeling of illness " (i.e., malaise), or of
" weakness " (debility, asthenia). He feels " generally " ill, and perhaps
looks ill, but may be imable to mention any localising symptom, such as
pain in the side or palpitation. Now, the first thing to do in such circum-
stances is to ascertain Whether he is feverish or not, because all such con-
ditions may be divided into two large clinical groups : A. Debility with
jyyrezia, which includes the Acute Specific Fevers and disorders in which
there exists some localised inflammation ; and B. Debility without pyrexia,
which includes the different forms of AnsBmia and various toxic and
nutritional disorders. The latter will be dealt with in Chapter XVI.
In this chapter we are concerned solely with the various conditions
attended by elevation of the body temperature.

§ 841. Definitioiit. — The term Aonte Specific Fever (or Specific Febrile Disease) has
been applied to those fevers which are due to a specific or special poison, introduced
into the body from without, and which run a definite course. If the poison was con-
tracted from a previous case, but without contact with the patient, it was said to be
an Infectious disease {e.g., scarlatina) ; if the disease was produced only by actual
contact with a person suffering from the malady, it was called Contagious (e.g,,
syphilis) ; but these terms have always been used somewhat loosely and indifferently.
It would be out of place to enter here into the question of the nature of this poison ;
but suffice it to say that there is direct or inferential proof in all the acute specific
fevers that it is of microbio or parasitic origin. At first the microbes themselves were
supposed to be the active agents of these diseases, but now in most cases the causa
vera of the pyrexia and other symptoms is known to be a toxin or toxins which are
produced by the microbe. This branch of knowledge has received enormous additions
to it during the last quarter of a century (c/. §§ 386 et seq.).

The subject of Bacteriology will be referred to in a later chapter, and it will be suffi-
cient to mention here the chief clinical characteristics which cause us to suspect a
disease of being microbic in origin. They are three in number :

1. The occurrence of the disease in question in an epidemic form — i.e., in the form
of an outbreak, or as a series of cases which suggest that the patients contracted
the disease either from one another or from a common source, the infection being con-
veyed to them through the air, the water, or other ingesta. Dietetic poisons (organic
and inorganic) must be excluded.

2. Two features are common to all microbio diseases : (1) Pyrexia is present at some
time during the course ; and (ii.) all the cases of disease run a definite course— definite
onset, gradual increase to an acme or fastigium, defervescence, gradual or sudden,
followed by complete restoration to health, or death.

459

460 P Y RE XI A §$ 842, 848

3. The constant presence in the blood, tissues or excretions of the patient of a
microbe or protozoan.

The pathological proof that a particular microbe is causally related to the disease
consists in applying certain experimental tests (see § 386).

Epidemic, Endemic, and Sporadic are terms by which it is usual to express the
relative prevalence of infectious diseases. A disease is said to be Epidemic when a
large number of cases arise by infection from a common source or from one another
at one time, followed by an interval in which none arise. Thus epidemics of measles,
scarlatina, and diphtheria arise in the Metroj^olis and elsewhere from time to time.
A disease is said to be Sporadic when it occurs only in isolated cases. Thus we speak
of a sporadic case of mumps when no other cases of it have been known to occur about
the same time and in the same district. An Endemic disease is one which is constantly
present in a certain district. Thus enteric fever is endemic in London, ague in Central
Africa and other marshy areas, and cholera in India.

PART A. SYMPTOMATOLOGY.

§842. Pyrexia and Symptoms which may attend it. — Pyrexia may in
some instances be imattended by any symptoms, but in nearly all cases the
patient whose temperature is elevated complains of feeling "chilly," or
he may have shivering or rigors ; or perhaps he feels " burning hot."
Headache, restlessness, and vague pains in the limbs and back are also
common symptoms, in addition to the malaise or weakness. His skin is
hot and dry to the touch, his pulse and respiration are rapid, his appetite
is bad, tongue furred, and bowels confined, his urine scanty and high
coloured. In severe cases of fever there is great prostration, considerable
mental dulness, and there may be delirium, or the " typhoid " state. By
these symptoms we suspect the presence of pyrexia, and the suspicion is
confirmed, and the degree of fever ascertained, by the clinical thermometer
(see below). The various stages through which microbic disorders pass
and the three important symptoms or conditions which are apt to be met
with in patients suffering from pyrexia — ^namely, Rigors, DELmiUM, and
the " Typhoid State " — will now be separately described.

§ d43. Incnbation and other Stages of Acnte Specific Fevers. — There is
nothing more characteristic of microbic or specific diseases than the
definite course which they run. It is a curious fact that a person does not
develop the disease directly after he has been exposed to infection. The
interval is called the stage of incubation. The patient may be quite well
during this stage, or feel a little malaise. Its duration is variable in most
diseases, and each disease differs from another (table, p. 461). This
period corresponds to the time during which a healthy person who has
been exposed to infection needs to be isolated (placed in quarantine, as
it is called), to see if he will develop the disease. A glance at the first
column in the table will show that a period of three weeks will cover the
incubation of all the eruptive fevers. The actual invasion or develop-
ment of the symptoms of the disease is more or less abrupt, except in
enteric fever, whooping-cough, and sometimes measles. An eruption
appears upon the skin within the next four days (except in enteric fever)
in those diseases which develop a rash, and which are called on that account

§844]

ACUTE SPECIFIC FEVERS— RIGORS

461

the Exanthemata. The fever and other symptoms go on increasing mitil
the acme is reached. Finally the last stage- the stage of defervescence--
supervenes, and gradually the patient convalesces.

Table XXI.— Showing Incubation, Date op Eruption, and Dura-
tion OF Infecjtion of the Principal Infective Disorders.

Disease.

Varicella.

Scarlet Feyer.

Incubation
Period.

10 to 19 days,
average 14.

1 to 5 days,
average 2|.

Day of Disease

ON WHICH

Hash appears.

The rash is usually
the Ist symp-
tom noticed.

Infectious Period,

or period during which the

patient need be isolated.

Till all scabs
2 to 4 weeks.

have separated,

2nd

Small-Pox.

Measles.

Rothela.

Typhus.
Enteric.

Dengue.
Diphtheria.

12 days.

7 to 14 days,
average 10.

7 to 21 days,
average 10.

3rd.

From commencement of illncM Ull
an indeterminable date, which
varies in different cases. Aver-
age 6 to 0 weeks. Rhinorrhoea,
and possibly otorrhcea, may
retain infection for 0 monUu
or more.

From commencement till not a
trace left of scabs or desqua-
mation. Most virulent in
vesiculation, pustulation, and
scabbing. 3 to 8 weeks.

4th.

Ist to 4th.

Rarely less than 12. 4th or 6th.

3 to 21 days,
average 10 to 14.

2 to 6 days.

2 to 6 days,
or more.

Averavte 2nd
week-
Initial rash Istday.
Terminal rash 4th.

None.

Great in early period before rash
out. Till scaling and cough
cease. Usually 2 weeki.

7 to 10 days from commencement.

Probably 3 to 4 weeks.

Several weeks after pyrexia has
ceased.

At least 21 days after disappear-
ance of membrane and all throat
mischief.

The period of incubation of the other microbic disorders so far as we know is given
approximately below. This is important, as the duration of quarantme depends on
the period of incubation.

Ague, 12 hours and upwards.
Anthrax, 2 or 3 days.
Gonorrhoea, 2 or 3 days.
Influenza. 3 or 4 days.
Plague, 3 to 7 days.
Glanders, 3 to 18 days.
Relapsing fever, 4 to 10 days.
Whooping-cough, 6 to 12 days.
I^Ialta fever, about 9 days.
Erysipelas, 3 to 6 days.

Cholera, under 14 days.
Yellow fever, under 18 days.
Tetanus, under 24 days.
Mumps, 12 to 24 days.
Syphilis, 15 to 26 days.
Hydrophobia, 40 days or more.
Tubercle, probably some weeks.
Pneumonia \

Septicaemia

Cerebro-spinal fever )■ unknown.
Infantile diarrhoea
Sprue

§ 344. Rigors often indicate the sudden onset of pyrexia. A rigor is an
attack of shivering attended by elevation of temperature, rapidly followed

462 PYREXIA [§844

(usually) by sweating and a fall in the temperature. Such an attack may
vary widely in severity from a simple feeling of " chilliness down the back,
like cold water," to a shaking of the whole body, so that the patient shakes
the bed beneath him. Severe rigors occur t3^ically and regularly in the
course of malaria, and also at frequent but irregular intervals throughout
the course of Septicaemia. In childhood, rigors are often replaced by
convulsions.

1. First, ascertain that the shivering is not of purely nervous origin,
because a trembling much resembling a rigor may occur as a result of
pure fright or from slighter causes in nervous people.

2. Procure, if possible, a series of temperature records, because rigors
occur in association with several conditions which can only be differen-
tiated in this way.

Causes, — The causes of rigors are very numerous, but they are best
approached in a general way as follows :

(a) Coming on in a person previously healthy, one should always suspect
the advent of some acute illness. In children the eruptive fevers are often
ushered in with either convulsions or rigors. In adults, pneumonia,
peritonitis, pyflemia, tonsillitis, the eruptive fevers, malaria or influenza
may be suspected.

(6) Sej>tic Infecti(m, — When rigors supervene in the course of an illness
of any kind, abscess or pent-up pus in some position should always be
the first thing thought of. Be/ore the days of the thermometer the doctor
used to rely upon shivering and sioeating as an infalUhle indication of the
formation of pus. In a case of pleurisy with effusion, for instance, which
has hitherto been serous, the occurrence of shivering indicates that the
contents of the chest have become purulent (empyema). Similarly, a
rigor occurring with otitis media suggests extension to the mastoid cells,
or it may point to cerebral abscess or sinus thrombosis. Rigors occurring
in a case of cardio -valvular disease indicate the occurrence of septic
emboli, or the supervention of malignant endocarditis. Shiverings and
sweatings are apt to occur during the course of tuberculosis and many
other conditions mentioned under the Causes of Intermitting Pyrexia
(§ 377). If no obvious cause for an attack of shivering appears, we may
suspect some internal ulceration or suppuration, such as appendicitis, or
ulceration in some part of the urinary, biliary, or alimentary canals. If
the rigor is due to a collection of pus, there will be foimd a definite leuco-
cytosis.

(c) Some shock to the nervous system may produce rigors. The passing
of a catheter is often followed by a severe rigor, and sometimes the tem-
perature goes suddenly up to 105° or 106° F., and as suddenly down again.
Irritating substances in the alimentary canal may produce rigors reflexly.
Sudden obstruction in the biliary or renal passages is often attended by
rigors, followed by a feeling of heat and sweating, and the temperature may
go up to 105° F. (Murchison). Severe pain, as in hepatic colic, may be
accompanied by rigor even when there is no fever;

§845] DELIRIUM 403

(d) Neurasthenic and hysterical patients are very apt to have shivering
attacks, but these are unattended by elevation of temperature. Attacks
of shivering may also constitute a symptom of vaso-motor disorder. It is,
for instance, a symptom of the reaction which follows, and often forms
part of the " flush-storms " chiefly met with at the climacteric — " flushes
and shivers," as the patients call them. In these also there is no elevation
of temperature.

The Prognosis and Treatment belong to the several causal conditions,
but in any case the patient should be kept warm in bed with a hot-water
bottle to his feet, and a full dose of opium, combined with bromide, to
soothe the nervous system, and in septic or malarial cases 5 to 10 grains
of quinine.

§ 845. Ddiriom, or incoherence of thought, is another symptom which
frequently accompanies pyrexia. The older authors used to describe
three varieties of delirium : (1) Delirium ferox, in which the patient is
very violent and maniacal; (2) typhoid delirium, in which the patient
lies on his back muttering, with subsultus tendinum ; (3) delirium tremens,
in which there is great sleeplessness, hallucinations and tremors, not
necessarily due to alcohol. The nature of the delirium is not always
constant in any given disease. For clinical purposes, the causes of delirium
may be divided into two groups — febrile and non-febrile. It is im-
portant, therefore, to take the temperature at once in every case of
deliriimi. Alcoholic subjects and children, especially if neurotic, are pre-
disposed to delirium when attacked with only slight fever.

a. Febrile Delirium, or delirium with elevati6n of temperature, may arise
under four circumstances :

1. Diseases of the Brain, such as tuberculous meningitis. This kind
is generally accompanied by pain in the head, retraction, vomiting,
intolerance of light, and paralysis of cranial nerves.

2. Acute Local Inflammations in other parts of the body, such as pneu-
monia. It is advisable, therefore, to examine all the organs of the body.

3. All the Acute Specific Fevers are liable to be accompanied by
delirium. The tendency, however, varies considerably, though it is
usually directly related with the height of the temperature. It is im-
portant to bear this in mind, because, as a prognostic indication, delirium
occurring in a disease like measles or acute rheumatism, in which it is rare,
has a much more serious meaning than when it occurs in pneumonia, for
instance, where it is usual (see Table XXII.). Occurring in acute rheu-
matism, it is generally an indication of pericarditis, endocarditis, or some
other serious complication.

4. Certain cases of Delirium Tremens of a severe kind are accom-
panied by an elevation of temperature. Indeed, the prognosis in this
affection may largely depend upon the t-emperature. We must be careful
to exclude local inflammations in such cases, for they are apt to come on
very insidiously. In the worst cases of acute delirious mania also the
temperature may be considerably elevated (see 6 6, below).

464

PYREXIA

t§»45

Table XXII. — Showing the Kelative Frequency uf Delirium

IN the Various Miorobic Disorders.

FrenuerU in —

Oecanonal in —

/tore in —

Ck>Dfluent Small-pox

Remittent Fever

Influenza

Typhus

Yellow Fever

Mumps

Lobar Pneumoaia

Small-pox (modified)

Dysentery

Enteric Fever (after Ist week)

Measles

Cholera

Meningitis

Relapsing Fever

Acute Rheumatism

Cerebro-Spinal Fever

Malaria

EryBipelas

Diphtheria

Plague

Rdthehi

Malignant Endocarditis

VariceUa

Scarlet Fever

Septicsemia

6. Non-febrile Delirium may arise under six conditions :

1. Delirium Tremens (Delirium e Potu) is, as just mentioned, usually
imattended by elevation of temperature, and is undoubtedly the com-
monest cause of non-febrile delirium. It is recognised by the history, the
muscular tremors, sleeplessness, and the characteristic hallucinations.

2. Chronic Renal Disease, and especially chronic interstitial nephritis,
gives rise in its advanced stages to a muttering delirium or incoherence,
which thus becomes a symptom of the gravest import, and generally
heralds coma and death. The delirium is due to uraemia, and occurs in
other renal diseases.

3. Post-Febrile Delirium (Post-Febrile Mania). — ^During the con-
valescence of pneumonia, <)nteric fever, and other exhausting diseases,
especially such as run a protracted course, and have been attended
with a high degree of pyrexia, mental symptoms may develop.
These symptoms, which — in most of the cases I have met with —
make their appearance without any warning, give great uneasiness to
the friends. Nevertheless, by means of good food, tonics, and fresh air,
such mental symptoms will entirely disappear.^ Before venturing on a
prognosis, however, inquiry should always be made for any family history
of mental disease, for a hereditary taint greatly lessens the chance of
recovery. The condition is recognised by the history of the previous
malady. Sometimes the mental derangement consists simply of loss of
memory, especially for the names of persons and things, but more often
the mind " wanders " and there are delusions.

4. Reflex Delirium. — Trousseau ^ mentions cases of children with
intestinal worms who had delirium, and several cases are mentioned by
the same author which were caused by the tickling of the soles of the feet.

^ A recent case of this affection which I have seen was that of a lady, sat. thirty-
nine, who, after a protracted illness with subacute rheumatism, developed mental
symptoms which lasted for some three months, until the administration of opium
gave her the necessary quiet, and she completely recovered. She had delusions,
wanderings at night, and serious loss of memory. She always addressed me as
•» Dr. DevilL"

^ Qmical Lectures : New Syd. Soo. Translation.

§ 846 ] DELIRIUM 466

The transient delirium connected with the severe pain of childbirth is
probably of the same nature. I am inclined to agree with Griesinger,i who
says that "mental diseases caused by intestinal wonns would be very
interesting and more practically useful if they could bear a closer investiga-
tion." Nevertheless, the transient delirium or mania met with at the
climacteric comes with some probability in this category, the reflex cause
being situated in the generative organs.

5. Delibiant Dbuqs should always be suspected when delirium develops
suddenly in a person in health, especially children in the country, in the
absence of any of the foregoing causes . The most important are belladonna ,
hyoscyamus, cannabis indica, stramoniimi, and others of the solanacese,
camphor in rare cases, oenanthe crocata, cocculus indicus (with which
beer used to be adulterated), poisonous fungi, and sometimes salicylic
acid in large doses. Morphia in some people invariably produces delirium.

6. AouTE Mania sometimes comes on very suddenly, and, as previously
mentioned, only differs from " delirium ferox " or maniacal delirium in
n(it being referable to some bodily disease or toxic condition of the blood.
We are enabled to identify this condition by (1) the temperature not as a
rule being elevated ; (2) by its affecting a person previously in good bodily
health ; and (3) the exclusion of any organic lesion by a careful examina-
tion, both of the nervous and other physiological systems. As regards
the temperature there is an exception in the rare and serious condition
known as " acute delirious mania," in which marked pyrexia is present.

Prognosis, — ^Febrile delirium is not necessarily a grave S3anptom when
it is associated with a disease in which its occurrence is usual — e,g,, pneu-
monia— and especially when the cause is only temporary ; but its presence
adds considerably to the gravity of a case if the occurrence of delirium is
unusual (see table, p. 464), for it indicates a very severe attack, or the
occurrence of complications, or both. Non-febrile delirium is a grave
symptom in chronic renal disease. The prognosis is serious as regards
recovery in all patients who have a hereditary tendency to mental dis-
order. In acute mania the prognosis is very grave.

Treatment, — It is necessary to provide a nurse or attendant, and re-
straint may be called for. Remedial Treatment. — An ice-bag to the head
for an intracranial inflammation ; good nourishing food for mania and post-
febrile delirium ; a brisk purge for uraemia. Alcohol is indicated if the
pulse is weak, but if it is strong and bounding, alcohol, as a rule, aggravates
the condition. In every case of febrile delirium the effect of alcohol
should be carefully watched, and its amount kept down as much as possible.
The symptomatic treatment consists of the administration of sedatives, such
as chloralamid, trional, chloral, and the bromides. Of these the former
acts best in most cases. Opium and morphia require caution. In delirium
tremens, for example, it does a great deal of good in some cases by pro-
curing sleep, but in others it only aggravates the maniacal condition. In
post-febrile delirium and other conditions where the brain is suffering

^ Griesmger on Mental Diseases : New Syd. Soc. Translation, p. 197.

466 PYREXIA LIS46

from malnutrition, opium in small doses is a most valuable remedy, and
may be given without fear if the kidneys are healthy.

§846. The l^hoid State may be described as a condition of uncon-
sciousness (coma) or semi-consciousness attended by elevation of tem-
perature and muttering delirium, due to a toxic condition of the blood.
The name of this condition was derived from its frequent association with
typhus, but it is met with in many other fevers. With reference to the
question of pyrexia, it should be stated that the comatose condition, due
to renal disease (ursemia), advanced liver disease, and various poisons
(particularly opium), has sometimes been described as the typhoid state,
but these are apyrexial conditions, and it is preferable to include only those
with pyrexia. In short, the typhoid state corresponds clinically to a state
of coma j)lu8 pyrexia and muttering delirium.

Symptoms. — The typhoid state is always secondary to some febrile
condition, in the course of which it arises. The first symptom usually
noticed is sleeplessness with delirium, generally of the muttering variety,
but by-and-by stupor supervenes, which gradually deepens. The mental
faculties are obscured, but the unconsciousness is not always so complete
as one would imagine. The tongue is dry, brown, and rough, and sordes
collect upon the teeth. The pulse is rapid, feeble, and irregular, and the
heart-sounds distant. The respiration is usually rapid, but shallow. The
pupils are dilated, but the patient does not see. Nevertheless, he looks
about at imaginary objects — " coma vigil." Dysphagia may supervene, and
is a very serious indication of profound stupor. Stertorous respiration only
occurs in like circumstances, and is another grave indication. The profound
disturbance of the nervous system is evidenced by prostration, restlessness,
subsultus tendinum (muscular twitchings), floccitatio (picking at the bed-
clothes), and, in extreme cases, convulsions. The temperature is elevated, its
height and course depending chiefly upon the nature of the primary malady.

Diagnosis, — (1) The " typhoid state,^^ as above mentioned, may be dis-
tinguished from coma by the presence of pyrexia, and the absence of
evidences of renal or liver disease, apoplexy, or other cause of the coma.
(2) Certain acute inflammations of the brain are, however, attended by
pyrexia, and offer conBiderable difficulty. This is particularly the case with
tuberculous meningitis. The presence of optic neuritis, retraction of the
head, paralysis of the cranial nerves on the one hand, and the signs of
the primary malady which has produced the typhoid condition on the
other, are evidences upon which we can rely in many instances.

Causes, — Patients with an alcoholic history are predisposed to the
development of the typhoid state. Renal fibrosis (chronic interstitial
nephritis) offers a similar predisposition.

1. The Acute Infectious Fevers are the conmionest causes, and
particularly typhoid and typhus fevers. The Typhoid State occurs as an
ordinary symptom of a grave attack in the course of these two diseases
and in some others (see Table XXm.). In another group of diseases it
occurs only occasionally, and in others it is rare. If it arises in either of

846]

THE TYPHOID STATE

467

these latter groups, it indicates either (1) a very severe variety of the
disease, or (2) sotae serious complication ; and, in any case, that the patient
is likely to die.

2. Certain other Inflammatory or Infective Disorders with local
manifestations may be attended by the typhoid state, such as acute lobar
pneumonia, acute pulmonary tuberculosis, ulcerative endocarditis, and
acute meningitis.

3. Certain acute Idiopathic Diseases may, in rare instances, be
attended by the typhoid state, such as acute gout and very intense forms
of delirium tremens. It is extremely rare in acute rheumatism, unless
accompanied by peri- or endo-carditis.

Table XXIII. — Relative Frequency of the Typhoid State in
Different Diseases. Alcoholic Subjects and Patients with
Granular Kidney are predisposed to the Typhoid State.

Frequently met with, especiaily
Uncards the end, in —

Typhoid (Enteric) Fever
Typhua

Confluent Small-pox (unmodified)
Erj'sipelas (severe)

Septicaemia (including Malignant Endo-
carditis and Osteomyelitis)
Meninffitis
Lobar Pneumonia
Acute Miliary Tuberculosis
Acute Glanders
Acut« Anthrax
Remittent Fever

Comatose and Hspmorrhagic Malaria
Yellow Fever
Plague

Occasionally met with in —

Scarlatina

Measles with broncho-
pneumonia
Cerebro-Spinal Fever
Anthrax (Internal)
Remittent Fever

Rare in-

Diphtheria

Cholera

Variola (modlfled)

Varicella

Dysentery

Malaria

Ilelapsing Fever

Acute Rheumatism

Diagnosis of the Cause. — The clinical investigation should be conducted on
the same lines as in cases of pyrexia. Is it due to local or generalised inflam-
mation ? First, every organ in the body should be thoroughly examined so
as to exclude local disorders. Secondly, we proceed to the diagnosis of the
general fevers from one another, and, if possible, obtain a series of tempera-
ture records. In cases where the cause of the typhoid condition is obscure,
septicaemia should always be suspected, and its origin carefully sought. ^

Prognosis, — The typhoid state, like delirium, has a less serious import
in diseases such as enteric fever, in which it is frequently met with. But
it is always a grave condition, and indicates profound cerebral depression.
Occurring in the course of scarlatina, erysipelas, or measles, it often in-
dicates pulmonaiy or cardiac complication, and is proportionately serious.
As regards sjTuptoms, the profundity of the stupor is a measure of the

^ While I was Medical Superintendent at the Paddington Infirmary a young woman
was brought in with all the symptoms of the typhoid state. The subsequent course
of the temperature and the occurrence of sweating and rigors declared the disease
to be septicaemia, which wa** trncod to a pelvic origin. She di'^d, and the case was
brought home to a professional abortionist, who was sentenced to penal servitude.

468 PYREXIA [§847

intensity of the microbic toxfiemia, and dysphagia, stertor, or convulsions
are generally lethal signs.

The Trealment of a condition such as this arising in the course of so
many diseases must necessarily vary, and our first duty is to ascertain
what disease is in operation. It is, however, due in all cases to the effects
of the toxin upon the central nervous system. The blood poison consists
partly of the microbic toxins and partly of the excessive nitrogenous
metabolism incidental to pyrexia. The indications are (1) to eliminate
the poison by diuretics, diaphoretics, and aperients ; and (2) to stimulate
and support the patient's strength by nutriment and stimulants. Alcohol
was formerly given in large quantities. At the present day more reliance
is placed on strychnine, which is best given by hypodermic injection.
Dr. Murchison treated patients admitted on alternate days into the London
Fever Hospital on opposite methods, and found that they recovered just
as well without alcohol ; though, on the other hand, it did no harm. In
practice, the state of the pulse and of the heart should be our guide. As
regards symptomatic treatment, if the delirium be very violent, sedatives
such as chloral or bromide, are indicated if the heart will stand them. For
this reason chloralamid is to be preferred. Opium should be avoided, as it
prevents the elimination of the poison. For the treatment of Hyperpyrexia,
see § 392.

PABT B. PHYSICAL EXAMINATION,

The clinical investigation of pyrexial disorders consists of (1) Clinical
Thermometry ; (2) An Examination of the Organs ; and (3) BaC"

TERIOLOOICAL INVESTIGATION.

§847. dinical Themiometry and Types of Pyrexia. — The temperature
is ascertained by means of the clinical thermometer.^ The temperature of
the body is usually taken in the axilla or the mouth. The temperature
may also be taken in the rectum, where it may be i° to 1° higher than in
the mouth. The temperature in the mouth is usually higher than in
the axilla, which is best regarded as the normal. In children the thermo-
meter may be held in the groin-fold or " crutch," the thigh being flexed
on the abdomen for the purpose. The normal temperature of the body
varies between about 97-8° and 99° F. ; average 98-4° F. It is highest
about 8 p.m., and lowest about 4 a.m. It tends to be lower in old age
and higher in infancy, especially after an attack of crying. The tempera-
ture is often subnormal after a loss of blood, during convalescence, in
cardiac failure, and in all states of collapse.

A temperature of 100° is regarded as slight fever.
„ „ 102** ,, moderate fever.

„ „ 104** „ high fever.

„ ,, 106** and upwards is regarded as hyperpyrexia.

^ Owing to the shrinkage of the glass, all elass thermometers are apt after a time
to read too high unless they have bNBen stored for months or years berore the scale is
marked and zero fixed. A clinical thermometer, for instance, may, at the end of a
year after manufacture, read a whole degree too high. Hicks, of Hatton Garden,
has patented a process of annealing thermometers which obviates this error, and does
away with the necessity of prolonged storage.

)M7] TYPES OF PYREXIA 469

The Teupbrature Chart. — Very little information can be derived from
a single (Aservation of a jMlienfg lemferature, and in all cages of fyrexia
one must know the course which it rung from day to day and hour to hour.
In most cases of fever it is hardly possible to come to any conclusion
■ without seeing a " chart " of the case — i.e., a aeries of records. In all
cases of pyrexia the temperature should be taken and recorded morning
and evening ; and in all acute cases it should be taken four-hourly. In
cases of suspected tuberculosis and some other affections it is important
to obtain hourly i«cords throughout the day, otherwise slight elevations
may be missed. The pulse and respiration should also be observed,
especially in abdominal inflammations, where the temperature alone does

rig. ei,— TtMB Of PnnxiA.— Continaoiu prteila ihowing only the normal v»ri»tlon» in tha
momlns and evening. RemltUnt pyrexia aliDwiDg a drop of teveial degrees aich day-
Intermittent pyreiia whBis tbe tempentuie comes down to ootnuJ at aame time eveiy day.

not give us a true idea of the amount of mischief which is going on. The
onset of the pyrexia may be gradual, as in enteric fever or diphtheria,
but more often it is sudden and accompanied by a rigor, as in scarlet
fever oi penumonia. Remember that the onset is apt to be very sudden in
scarlatina, small-pox, and erysipelas ; it is gradtutl (taking perhaps two
or three da}^) in measles and pertussis. During the next few days the
temperature generally increases until the acme is reached. The termina-
tion may be gradual, when it is said to terminate by lysis, as in enteric ;
or pyrexia may terminate suddenly by crisis, as in pneumonia.

Types ol Pyreria.^In the absence of any eruption, the COURSE oF THE
TEMPERATURE is our bcst, and may be our only, guide. It is usual to
describe three types of pyrexia, according to tha course which the tern-

470 PYREXIA [§848

perature pursues from day to day (Fig. 91) ; (i.) Continued or Continuous
Fevety where the temperature remains elevated for a considerable period,
and where the diurnal variation often doe^ not exceed the normal diurnal
variation — viz., one, or at most one and a half degrees ; (ii.) Remitting
Pyrexia, when the diurnal variation is greater than the normal diurnal
variation, but where the temperature never comes down quite to normal ;
(iii.) Intermitting Pyrexia, where the temperature at some time of the day
is normal or subnormal, and at another time of the day, usually in the
evening, it is raised one, two, or more degrees. But for clinical purposes
the two latter may be grouped together, and thus we have two groups
of fevers — one in which the pyrexia is practically continuous, and another
in which there is a remission, or intermission, once or oft^ner during the
twenty-four hours, usually in the morning.

The following are useful facts to remember concerning temperatures :
(i.) The sudden advent of high fever in a previously healthy person with-
out other symptoms indicates, in England, Scarlet Fever, Diphtheria,
Small-pox, or Erysipelas, and sometimes Pneumonia. A very gradual
advent is suspicious of Enteric Fever, (ii.) A fresh rise after the tempera-
ture has begun to fall indicates a complication or a relapse, (iii.) A sudden
fall in the course of a fever (especially Enteric Fever) may indicate internal
haemorrhage, perforation of the peritoneum or pleura, or profuse diarrhoea,
(iv.) A considerable rise in diseases usually non-febrile, such as tetanus,
delirium tremens, cholera, cancer, epilepsy, apoplexy, etc., generally
indicates a fatal termination.

§ 848. Subnormal Temperature. — The temperature of the surface of the body as
indicated in the axilla, is rarely moie than one or two degrees below normal. When
it is below 96° the condition usually amounts to collapse. Subnormal temperature
is not so important, for purposes of diagnosis, as elevation of temperature ; but in the
first four mstances given below it may aid us in their diflercntiation. Subnormal
temperature adds to the gravity of the prognosis in most wasting disorders. In regard
to treatment, temperature readings below the normal are indications for the adminis-
tration of stimulants, nourishment, and the application of external warmth.

Cavses. — 1. Subnormal temperature as an indication of lowered vitality occurs in
normal circumstances in the aged, in whom the temperature is habitually several
fractions of a degree below normal.

2. A subnormal temperature is of considerable diagnostic significance in the
prodromal stcige of tubercle, and especially tuberculous meningitis. If a carefully
recorded series of temperatures in a person suspected of tubercle show a subnormal
morning and evening temperature (or vice versa), it adds to our suspicions.

3. The temperature takes a sudden drop in internal haBmorrhago or perforation of
the bowels. In enteric fever this sudden fall may l>e the only indication of these serious
complications. The rupture of an abdominal cyst, or of an intt^nial organ, such as the
spleen, liver, or kidney (very rare apart from injury), is attended by a sudden lowering
of the temperature ; but these conditions are also attended by other and more dis-
tinctive signs.

4. In all severe abdominal inflummations prostration and collapse are marked
features, and the temperature may in some casv's be subnormal, although there may
be considerable constitutional disturbance, as shown by the prostration, and the
rapid pulse (§ 165).

5. Subnormal temperature occurs in several other disorders in which it is not of
much diagnostic significanco, because we depend ui>on other signs for their identifica-
tion. Thus, the temiHTaturo of the body is lowered (i.) when there is an excessive

H 848-851] EXAMINATION OF ORG ANa 471

withdrawal of heat from the body, as in oases of exposure combined with privation,
or with extensive weeping skin eruptions ; or when large quantities of fluid are
evacuated, as in severe diarrhoea or cholera (when the temperature may be 90° in
axilla, though 105^ in rectum) ; (iL) in states of inanition or cachexia — e.gr., during
convalescence from fevers, Addison's disease, cancer (especially of the alimentary
canal), diabetes, and chronic mental disorders ; (iii.) when there is deficient oxygena<
tion, as in cases of congenital heart disease, cardiac failure, alcoholism, jaimdice,
ursamia, pernicious anaemia, and acute yellow atrophy ; (iv.) in some diseases of the
central nervous system, such as tubercidous meningitis, the onset of cerebral hemor-
rhage, or cerebral tumour ; and (v.) in poisoning by phosphorus, atropine, morphia,
carbolic acid, and other irritants.

6. In all states of oollapsb the temperature is considerably lowered (2° or more).
Indeed, this is one of the chief means by which it may be distinguished from
syncope.

§849. Ezaminatioii of Organs. — All the visceia must be carefully

examined in accordance with the Scheme of Case-taking, pp. 6 and 7, so

that local causes for the pyrexia may be excluded. For dmioal purposes

there are two great groups of causes of pyrexia : (a) local inflammations

such as pleurisy, appendicitis, abscess of the liver, etc., on the one hand ;

and (b) general inflammatory (constitational) conditions, like scarlatina,

rheumatic fever, and pyaemia, on the other.

If any local inflammation is found, turn to the chapter dealing with the disease of
that part. But it must still be remembered that some constitutional disease {e.g.,
some specific fever) may be present, of which the local disease is a complication. Thus
pneumonia, which would be discovered in the course of our examination, is a frequent
complication of enteric fever ; and endocarditis of rheumatic fever. There are two
features which may lesul us to suspect a combination of disorders such as this : ( 1) The
signs and symptoms of the local disorder may be of an aberrant type (e.^., see Aberrant
Types of Pneumonia, § 876) ; and (2) the constitutional disturbance presented by the
patient would be greater in degree or different in kind than would accompany the
local disease if it were the only disease present.

§ 350. The Examination of the Blood often affords most valuable infor-
mation, and it may be useful to make a blood-count or stain a film (§§ 397
and 398), to take a few drops of blood for the purpose of testing the Widal
reaction or the opsonic index, or to take a larger specimen of blood for
bacteriological examination. For the Wassermann test about 5 c.c. are
taken, usually from a vein in the forearm.

PABT C, THE DIAGNOSIS, PBOGNOSIS, AND TREATMENT OF

MICROBIO DISORDERS.

§ 851. Routine Procedure and Classiflcation. — ^In cases of pyrexia we
must investigate, as in other cases, three points :

First, THE Leading Symptom complained of by the patient will be one
or more of those mentioned in § 342.

Secondly, the History op the Illness. The date when the symptoms
commenced — i.e., the precise duration op the illness — is a most
important matter. A few of the fevers — e.g., enteric fever and diphtheria
— commence insidiously ; but the majority are ushered in suddenly, very
often with an attack of shivering (a rigor). Throughout the entire course
of every case of fever the physician should have constantly in mind the

472 PYREXIA [§861

" day of the disease,"! so that he may know what events to expect at that
particular period of the case. In enteric fever, for instance, on the
fourteenth day, or a little later, the diurnal range of the tempera-
ture should commence to be more marked, and during the next
few days special care should be exercised to avoid haemorrhage or
perforation.

Thirdly, the Examination of the Patient comprises three important
matters : (1) Physical examination ; (2) is there, or has there been, an
eruption ? and (3) the temperature and its course.

(1) Every groan must be systematically examined (Scheme of Case-
taking, pp. 6 and 7), and as carefully and thoroughly as the patient's
condition will allow, in order that we may detect or exclude any local
DISEASE. This is important, because all cases of pyrexia are associated
with or due to some local inflammatory disease, or some generaliied
febrile disorder (eg., enteric fever), or both.

(2) Whether there is or has been any eruption is the next question.
The first of the groups (vide infra) into which all fevers may be divided
comprises those in which an eruption distinctive of the disease appears
within the first four days (with one exception) after the illness. The day
on which it appears in each disease should always be at our fingers' ends
(table, § 343).

(3) The Temperature and its course is the next thing to investigate ;
and it is of the greatest importance to obtain a chart or succession of
readings, after the manner described in § 347. The duration of the fever
is of assistance in diagnosis, especially when it has lasted longer than two
or three weeks.^

The dassiflcation of pyrexial disorders may conveniently be based upon
the results of our examination — namely, the eruption, if present, and the
course of the temperature.

Group I. — Exanthemata or Eruptive Fevers — i.e., fevers which are
characterised by an eruption distinctive of each disease appearing on
one of the first four days of the ilbiess (§ 352).

Group II. — Continued Fevers — i.e., fevers in which the temperature
J uns a more or less continuous course, and which present no eruption
during the first four days (§ 363).

Group III. — Intermittent Fevers — i.e., fevers in which the tem-
perature nms an intermittent (or remittent) course, and which present
NO ERUPTION (§ 377).

^ Students do not always understand qniie correctly the meaning of this phrase.
For instance, the fourth day of a disease is the third day after its commencement.
Thus the eruption of measles appears on the fourth day, and, supposing the patient
were taken ill on a Monday, the eruption would appear on Thursday.

^ Excluding diphtheria and the exanthemata, it is found that the majority of
short fevers, of a few days* duration, are due to " common colds," " rheumatism,"
"constipation," and "influenza." "Colds," including bronchitis, influenza,
tonsillitis and pharyngitis -4,164 ; acute appendicitis, 1,504 ; acute arthritis, 1,016 ;
salpingitis, 871 ; pneumonia, 803 ; lymphangitis, 365 ; sinusitis, 259 ; erysipelas, 241 ;
poliomyelitis, 227— R. C. Cabot, " Differential Diagnosis." London, 1911.

f852j VARICELLA OR CHICKEN-POX 473

If the physical examination reveals signs of disease of some particular
organ, reference should be made to § 349, and to the chapter on diseases
of that organ.

GROUP L THE EXANTHEMATA OR ERUPTIVE FEVERS.

In all the diseases in this group the onset of the pyrexia is more or less
abrupt, and in the majority a well-marked general eruption appears
during the first four days of the illness. The course of the pyrexia varies
considerably in the disorders in this group.

Common. Rare,

I. Chioken-pox (first day) . . § 352 VIII. Dengue (first day) . . §359

II. Scarlet fever (second day) § 363 IX. Typhus (fourth or fifth day) § 360

III. Erysipelas (second day) ' . . § 354 X. Anthrax (first day) . . § 361

IV. Small-pox (third day) . . § 355 XI. Acute glanders . . . . § 362
V. Measles (fourth day) . . § 357

VI. Rotheln (first to fourth

day) § 358

VII. Enteric fever (usually tenth day),
influenza, cerobro-spinal men- t
ingitis, plague, and other mem-
bers of Group II., occasionally
present early rashes.

In each of the exanthemata the bbuption has special and distinotive characters
of its own, which, together with the day of the disease on which the eruption
appears, may enable one to differentiate the members of this group from one another.
Scarlet Fever may be regarded as the type, but it will be convenient to take them
in the order in which the eruption appears. Typhus is hardly ever seen at the present
day. DsKQUB is not met with in England. Anthrax and Glanders are, like
hydrophobia, derived from the lower animals.

§ 852. I. Varicella or Ghicken-Poz (synonyms : Variola CrystalUna,
SpirisB, NathsB, Ligitime, Glass-pock, or Water-pock) may be defined as
an acute contagious disease, manifested by an eruption of successive crops
of limpid vesicles, usually accompanied by slight exacerbations of fever.
It is in most cases a trivial disorder of childhood. A hundred years ago
it was described as a spurious form of small-pox (Heberden), and con-
founded with it till later years.

Symptoms, — The rash is generally the first sign noticed, though it may
have been preceded by a feeling of " chilliness " or feverishness one to
three days before its appearance. It consists of pink, slightly raised,
ovoid, or somewhat pyramidal papules, which in the course of twelve or
twenty-four hours become vesicular. The typical vesicle is at first a thin-
walled, translucent, glistening bleb, containing a clear fluid, which after
a day or two becomes opaque and cloudy. The vesicle, meanwhile, loses
its tension and dries up into a scab, which finally separates within ten
days or a fortnight, but rarely leaving any extensive scarring. Some of
the papules do not proceed to vesiculation at all, the papular phase
persisting. The essential feature of this eruption is that it comes out
in successive crops, and consequently we see difierent stages of the rash

474 PYBEXIA [$S«S

on the same area of skin. This process goes on for about a week, when the
disease may be considered to terminate. The rash starts on the chest and
neck, and usually invades the whole body except, perhaps, the face and
hands (the most frequent situations in small-pox). It may invade the
mucous membranes, the palate being most often affected. The whole
disease seldom lasts longer than ten days, and it may be so trivial as to
pass unnoticed by the patient. The temperature rarely exceeds 103° F.
A case ceases to be infectious after the scabs have separated. The period
of incubation is fairly constant. Although the limits may be stated as
from eleven to twenty-one days, it is usually about a fortnight.

Diagnosis, — Modified Variola is the chief disease from which it has to
be differentiated, although this should not be difficult, because in small-
pox (i.) the rash comes out definitely on the third day ; (ii.) it does not
appear in successive crops ; (iii.) its favourite situations are the face and
wrists ; (iv.) the evolution of the pock is much less rapid ; and (v.) the
constitutional symptoms are very definite and characteristic. Herfes is
distinguished by the limited area, and grouping of the vesicles. Pemphigus
is distinguished by the size and chronic character of the blebs. Dermatitis
Herpetiformis is distinguished by its chronic character, by the vesicles
occurring in groups, and irritation is usually severe.

Etiology, — Varicella is essentially a disease of childhood. It occurs in
epidemics, for the most part, of limited extent, though it is endemic in
London. One attack usually confers immunity, but there are many
reported cases of second or even third attacks. Other infectious fevers
predispose to it.

Prognosis, — Deaths are very rare. An attack is usually over in a week
or ten days, but it is apt, particularly in adults, to be followed by weakness,
which indeed may be more troublesome than the disease itself. Untoward
symptoms, such as gangrene and haemorrhage into the vesicles, are rarely
met with. Complications are few in number, the chief one being impetigo.

Treatment, — The itching is generally the chief trouble, and this may
be relieved by chloral, creolin baths, or calcium chloride. Sponging the
surface with carbolic lotion, 1 in 20, is very useful. The child should be
prevented from scratching the pocks, as it causes suppuration and con-
sequent scarring. Quinine and arsenic are the best remedies for the
resulting weakness.

§ 858. II. Scarlet Fever (synonym : Scarlatina) is one of the most serious,
and one of the conmionest, of the eruptive fevers. It may be defined as
a contagious febrile disease attended by inflammation of the tonsils, and
a punctiform eruption on the skin, followed by desquamation. There are
five characteristic Symptoms, (1) After a period of incubation which
varies from one to five days, though usually two to three, there is a sudden
advent of high fever. The occurrence of this sudden pyrexia is of itself
extremely characteristic of scarlet fever, small-pox, and erysipelas, and,
occurring in a child previously healthy, is always suspicious of scarlatina.

$ 8n ] SCARLST FEVER 4,15

Vomiting also occurs iu 80 per cent, of the cases (Caiger).^ The tompera-
ture gradually subsides to normal about the fifth or sixth day in mild
cases. It does not, as in small-pox, subside when the rash comes out
(Fig. 92). (2) A sore throat appears on the first day, with the fever, and
gives a characteristic scarlet colour to the fauces. The swelling is greatest
about the fourth day in simple cases. Sore throat occurs with several of
the exanthemata. In scarlet fever it is the tonsils and pharynx that are
affected (never the larynx) ; in measles the larynx is chiefly affected ; in
small-pox both the larynx and pharynx are involved. The infiammation
may become very severe, and is always attended with more or less glandular

Fig. 9%. — SciKLKT FsvEH. — Arthoi M , xl. 5. A typical mild csm, specially w tegard* ths

InltUI Bymptoma, the rub, the tongue, and the desquamation. The varlooi IncldBnU are
shown oci tlifl chut, lot which the author is indebtad to Dr. F. F. Cslser.

swelling. (3) The eruption is the next symptom, and it is generally
remarkably regular in its appearance— twenty-four to thirty-six hours
after the advent of pyrexia. It has two elements — a generalised red
blush, disappearing on pressure, and a number of minute points slightly
raised and redder than the surrounding skin. It appears first on the
front of the chest, axiUte, and arms, and is last developed on the limbs,
affecting finally the hands and feet ; but on the palms and soles there is
no punctate oi papular eruption as there is in measles. The face is flushed,
but has no punctiform rash either. It continues well marked until the
fourth or fifth day, then declmes, and is generally completely gone by the
jlijoct in Dr. W. H. .^llrbin's " Manual of

476 PYREXIA [§S58

seventh or eighth day, except on the outer sides of arm and legs, where
for several days there often remain a number of coarse injected papules.
(4) The strawberry tongue is seen typically about the fourth day. It is
due to the stripping of the fur, which leaves a bright red denuded surface,
with marked fungiform papillse. (5) Desquarnation is apt to occur with
any severe skin inflammation, but it is more characteristic in this than
in any other fever. It begins about the fourth day, and continues for from
four to six, or eight weeks — first on the face, and, following the order of
the rash, last on the palms and scleSy the complete desquamation of which
may be very tedious. In the latter position the flakes are large ; elsewhere
they are small and shreddy.

Varieties, — There are, according to Dr. F. F. Caiger, three chief varieties :
(1) The Benign, simple or ordinary type as above described. Various
symptoms — e.g,y rash or sore throat — may be absent, and these cases are
spoken of as latent. (2) In Septic Scarlet Fever, Scarlatina Ulcerosa, or
Anginosa, " the ordinary symptoms are aggravated by the presence of
faucial ulceration, which, in addition to being a serious lesion in itself,
provides a focus from which septic material is absorbed into the system "
(Caiger, loc, cit,), (3) In the Toxic form the patient is seized with high
fever, delirium, and perhaps convulsions ; the rash is very intense, but the
throat symptoms, perhaps, ill-marked, and the patient dies during the
first week. Toxic scarlet fever of such intensity as to deserve the name
Malignant or Typhoid Scarlet Fever, in which there is low muttering
delirium, usually a marked rash, and death without complications in a
few days, is a very rare variety at the present day. In the HoBmorrhagic
form petechisB appear under the skin and mucous surfaces.^ These last
are intense varieties of the toxic form.

Diagnosis, — The diagnosis of scarlatina is not difficult in typical cases.
The abrupt advent of high fever, accompanied by vomiting and sore throat
in a child who has not had the disease, is always extremely suspicious, and
if the disease is prevalent the diagnosis is almost certain. During the first
few dayu the greatest difficulty is sometimes experienced in the diagnosis
from quinsy, in which there is frequently albuminuria at the onset but less
stupor and lethargy, generally less fever, and the history of previous
attacks of quinsy. Slight albuminuria may be present in both con-
ditions during the early stages. Without the eruption it may be impossible
to come to a definite conclusion, though the occurrence of vomiting in the
early stage, and the development of the " strawberry tongue " may assist
the diagnosis. In doubtful cases it is best to act as if the graver disease
were present (see Table X., § 111). Diphtheria has no punctate rash,
though a flush may be seen on the chest and arms, but the characteristic
membrane appears on the throat (see Table X.). Dengue {q.v,) is accom-
panied by severe articular pains and a morbilliform eruption on the fourth

^ 8urgic€d Scarlatina is an unfortunate name suggested for an erythematous rash,
aooompanied by constitutional symptoms, which sometimes occurs in surgical cases.
The nature of such cases varies ; they may or may not be scarlet fever.

§868] SCARLET FEVER ^11

day. The diagnosis is easier when the eruption is present. The scarlatinal
rash is distinguished from the rare prodromal erythema of smaU-pox by
the fact that the latter starts in the groins or axillee, and that it invades
the oral circle if the rash is dilEuse, and lumbar pain is usually complained
of. Enema rashes and Epidemic Exfoliative Dermatitis are sometimes
mistaken for scarlatina. A septic rash may be scarlatiniform, but is dis-
tinguished by fever of a pysemic type, and the presence of a septic focus,
and by the absence of characteristic punctation. The erythema of bella-
donrM, poisoning is accompanied by great thirst and dilatation of the pupils.
It is, moreover, imattended with pyrexia. Copaiba rashes and those due
to so-called " ptomaine poisoning " may be a source of confusion.

Etiology. — Delicate children and puerperal cases have a strong pre-
disposition to the disease. It is a highly infectious malady, especially at
the outset and during early desquamation. The infection is propagated
through the air, and carried by books and clothes, and is not infrequently
conveyed by infected milk. The patient is generally regarded as infectious
until desquamation has ceased from the palms or soles, a period averaging
four to six weeks, or even longer. There is no evidence, however, that
the later desquamation of scarlet fever is ever infectious, traditional belief
notwithstanding. One attack usually gives immunity for a lifetime, but
by no means always. The disease is most prevalent during the autumn
and early winter.

Prognosis. — It is always a serious disorder, because of the liability to
complications, especially renal and ear disease. These dangers are avoided
to some extent by keeping the patient in bed. Murchison used to teach
that if a patient had been con&ied to bed three weeks, nephritis rarely
supervened. This point is of the greatest importance, as it is as likely
to follow slight as severe cases. After the fourth week there is little
danger of nephritis. The aggregate case-mortality under five years of
age is about 5 per cent., but it varies in different epidemics. Over five
it is less than 2 per cent., and is lowest between puberty and thirty years
of age. The hsemorrhagic and malignant forms of the disease are those
attended by most danger, although a septic attack in a young child is very
likely to prove fatal. The danger varies with the malignancy of the
symptoms, especially the throat s3rmptoms, and the cardiac indications.
Persistent vomiting indicates a severe attack. Delirium at night is more
or less usual in bad cases, but violent delirium or stupor is a bad sign.
A temperature of over 105° F. is a serious symptom. The disease often
carries off the healthy and well nourished, and sometimes spares the
delicate patient ; but in the puerperal state and in tuberculous patients the
prognosis is very grave.

The Complications and Seqadm are very important, for they may cause
death, even after slight attacks. A considerable change has taken place
in the nature of the complications and sequelae met with in recent years,
partly, no doubt, owing to improved methods of treatment. Acute
nephritis and tonsillar or retropharyngeal abscess used to be re-

478 PYREXIA [§858

garded as the chief dangers, but at the present day Dr. Caiger^ gives
otorrhoea and otitis media as the most important complications, attacking
15 per cent, of all cases, and leading, occasionally, to permanent defects
in hearing, while intracranial abscess, septic thrombosis, and other septic
conditions may ultimately follow if the ear disease be not cured. Next in
order come simple albuminuria, attacking 7-9 per cent., definite acute
nephritis, 4 per cent., together totalling 11*9 per cent., and cervical
adenitis 114 per cent. Acute nephritis appears usually at the end of the
third week, very rarely after the fourth, its advent being indicated usually
by vomiting and dropsy. Articular rheumatism 6-7 and secondary ton-
sillitis 3-1 per cent, are met with, chiefly among adults. The other pro-
portions given by Dr. Caiger are ulcerative stomatitis, 1*7 per cent. ; and
broncho-pneumonia, 1 per cent. Brawny swelling in the neck, cancrum
oris, and noma pudendi are occasionally met with, and may need prompt
surgical measures. Acute endocarditis and pericarditis rarely occur
among the cases treated at the Metropolitan Asylums Board's Hospitals,
whatever their incidence in cases treated in their own homes. Among
the sequdcB subacute rheumatism and chorea are perhaps the chief.

Treatment. — The general treatment is dealt with in §§ 391 et seq,, but
it will be well to make a few remarks on the symptomatic treatment.
The throat is best treated by a chlorine gargle (F. 18). In children this
may be applied by means of a syringe or a spray ; nitrate of silver and
other caustic applications so long in vogue only aggravate the condition.
For the glandular swellings apply glycerine and belladonna, or warm
fomentations. Brawny swelling of the neck is a serious complication,
and must be dealt with by early incision and frequent carbolic fomenta-
tions. For ursemic convulsions give a drastic purgative (croton oil) and
a hot air or steam bath, supplemented, if necessary, by pilocarpine injec-
tions. Venesection may be tried if the convulsions persist, and the
spasms may always be kept under with the aid of a few whiffs of chloro-
form. The patient should be kept in bed for three weeks, whether the
attack be slight or severe, chiefly to prevent renal complications. As
regards immunisation, the micro-organism of Scarlet Fever has not so
far been isolated, so that we are not yet in possession of either an anti-
serum or a vaccine. 2 Nevertheless, in view of the numerous septic
complications of the disease, antistreptococcus serum has been tried by
various observers. Its use, however, has been for the most part dis-
appointing.3 The hygienic treatment is considered in §§ 389 ei seq,, but
a study of the long list of infective complications given above will show

^ Dr. F. Foord Caiger. The complications of scarlet fever based upon an examina-
tion of 10,989 cases treated in the South Western Fever Hospital, Stockwell, daring
the years 1895-1904 inclusive.— Clifford Allbutt's " System of Medicine," vol. ii.,
parti., p. 452.

^ Dr. W. J. Class has isolated a diplococcus having specific characters from the
throat and blood of patients (the Lancet, September 29, 1900). Gordon and Klein
have isolated a streptococcus.

* See a case complicated by acute otitis media treated by antistreptococcus serum,
with recovery. — Low, Lancet, 1898, voL i., p. 779.

1 864 ] ER 7 81 PE LAS 479

how important it is to treat this malady in a large and airy hospital
instead of at home. The throat is in a highly vulnerable condition, and
it is doubtless through this portal, or through the nose, that the various
infective organisms &id entrance.

§ 854. III. Erysipelas (synonyms : The " Rose," or " St. Anthony's
Fire ") may be defined as an acute febrile contagious disease, character-
ised by a progressive marginated redness and tumefaction of the skin,
usually attacking the face, or the neighbourhood of the wounds. (1) The
Stage of Invasion, — After an incubation period of three to six days the
advent is abrupt, as in small-pox and scarlatina. The temperature on
the evening of the same day may be 103° to 104° F., or more. Vomiting
is very common, and so also are muscular pains, especially pain in the
back,^ like that of small-pox. (2) The Eruption begins about twenty-four
to thirty-six hours after the advent of fever, as a red spot on the face or
at the site of an abrasion (which may be microscopic). It enlarges, spreads,
becomes bright red, tender, and pits on pressure. The advancing edge
is sharply defined and raised, the receding edge indefinite. The eruption
may vary in duration from three or four days to a fortnight. Delirium
at night is not unusual. Convalescence becomes established, and desqua-
mation occurs in the course of one to three weeks. During this last stage
albumen may appear in the urine, if it has not appeared before.

Diagnosis. — Erysipelas is to be diagnosed from erythema complicated by
cellulitis, in which the margin is less raised, and there is less fever. In
h'irpes of the first division of the fifth nerve vesicles occur in groups, are
limited to one side of the face, and are unattended by fever.

Varieties. — (i.) Phlegmonous erysipelas or gangrenous erysipelas are
severe varieties with suppuration or extensive sloughing, (ii.) Erysipelas
neonatorum is a very fatal variety ; death may be due to peritonitis by
inflammation spreading along the umbilical cord, (iii.) Erysipelas of the
fauces is a severe variety, the eruption spreading to, or starting in, this
situation. The disease may spread to the larynx and cause fatal dyspnoea.

Etiology, — It is a highly contagious malady. Persons are predisposed
to it, especially alcoholics, by wounds and unhygienic conditions. It
seems possible that even in so-called idiopathic cases the virus is intro-
duced into the system through a minute and hardly visible scratch. The
presence of a wound is the strongest predisposing cause, and it spreads
amongst surgical patients with great rapidity. As regards age, infants
and pel sons over forty are most liable. The disease is due to a variety
of streptococcus. One attack gives no immimity ; on the contrary, it
predisposes, and some elderly people are liable to an attack of facial
erysipelas every year.

Prognosis, — The ttsual course is favourable, but the disease is dangerous
in infancy or old persons, alcoholic or plethoric patients, and those affected

^ This is not usually mentioned as characteristio of erysipelas, and the first case
I was called to I mistook for small-pox on this account. I have never met with a case
in which it was absent, excepting in second or third attacks of the disease.

480 PYREXIA [§t56

with chronic diseases. Death may occur by coma or sjrncope, preceded
by incessant vomiting ; or by the supervention of complications. Hyper-
pyrexia, persistent vomiting, lividity of the rash, and t3rphoid delirium
are untoward symptoms.

Camplioations, — (i.) Subcutaneous abscesses either on the scalp, or in
the neck, or elsewhere ; (ii.) diffuse cellulitis, ending often in extensive
sloughing; (iii.) acute oedema of the glottis from the extension of the
eruption (a very serious complication) ; (iv.) hypostatic congestion of the
lungs (very common), bronchitis, lobular pneumonia, pleurisy ; (v.) perito-
nitis, especially when it occurs after parturition, and gastro-enteritis ;
and (vi.) nephritis, acute or chronic, though it is not so common as after
scarlet fever — are some of the commoner complications, (vii.) Meningitis
used to be mentioned as a frequent complication on account of the fre-
quency of cerebral symptoms in erysipelas ; but meningitis does occa-
sionally occur, (viii.) Chronic ulceration or skin eruptions often disappear
after an attack of erysipelas near them. This has happened even in the
case of ulcers which have been of a malignant character.^ (ix.) Pyaemia
and ulcer of the cornea are among the sequelae.

Treatment (Hygienic Treatment, see §§ 389 et seq,), — ^A mild aperient
should be given when the eruption comes out, and this should be followed
by iron in large and frequent doses — 20 minims of the liquor ferri per-
chloridi every four hours. Ammonia and bark are sometimes given ; and
in Germany large doses of quinine. Alcohol may be required in large
quantities. Warburg's tincture is useful. Tannin or liquor ferri per-
chloridi are sometimes applied locally for the pharyngitis. The benefit of
the latter, however, is very doubtful. Local Treatment, — Antiseptics,
or a dusting powder of starch and zinc oxide, or a lotion of acetate of lead
and extract of opium (4 grains of each to the ounce), should be applied to
the inflamed area. The eruption may sometimes be stopped by a sub-
cutaneous injection of carbolic lotion, 1 in 20, along the margin. Some say
it may be stopped by painting the advancing edge with nitrate of silver or
ichthyol. Daily inspection must be made for abscess whenever the skin
is tense ; scarification relieves the tension, and may prevent the occurrence
ot suppuration. Immuniaatian is now obtainable by the use of antistrepto-
coccus serum, and cases have been cured in this way (§ 386).

§ 856. IV. Small-poz (Variola) is a highly contagious eruptive fever,
the eruption passing through the stages of papule, vesicle, pustule, and
scab. In small-pox unmodified by vaccination the symptoms are as
follows : (1) After a very definite period of incubation of twelve days,
characteristic constitutional symptoms occur — ^viz., sudden advent of high
fever (101° to 104° F.), with severe headache and pain in the back. The
most noticeable features of this primary fever are the severity of the pain
in the back (which, in my experience,^ is present even in the mildest cases),

^ It hAB been suggested to inoculate erysipelas as a means of cure in this oondition
{vide Carcinoma).

' Report on tiie Warrington Small-pox Epidemic, by Dr. T. D. Savill ; Blue Book
ol the ^yal Commission on Vaocination. Eyre and Spottiswoode, London, 1895.

! SU ] SMALL-POX 481

and the frequent occurrence of vomiting. During the stage of primary
fever there is, as a rule, no eruption, but in a few cases a prodromal rash
makes its appearance. This may be (i.) erythematous, generally found in
the groins or other folds, occasionally it covers the whole body, in which
case the outlook is very grave ; {ii.} morbilliform, usually occup3dng the
apron area, but also occasionally difiuse ; or (iii.) a hiemorrhagic eruption
sometimes appears on the anterior surface of the abdomen and thighs.
Prodromal rashes appear about the second day. The fever remains up
until the third day, when the eruption appears. It then drops considerably
— the patient, indeed, may feel comparatively well. About the seventh
or eighth day, when the spots become pustular, a secondary ot suppurative
fever develops, which may be attended by rigoia (Fig. 93). This secondary

Fig. vs. — UMMODinm Small-poi. — Seven conflnent cue, uavacciuted, tcrmjiutlng ia n

fever lasts six or eight days, (2) The eruption appears between the third
and fourth day after the illness has commenced (fourteen days after
infection), first as a crop of papules of ehoUy hardness, which can be felt
even more readily than they can be seen, like small shot beneath the
skin (Coloured Plate I.). They first appear on the face and on the fronts
of the wrists, and then the eruption travels downwards over the whole
body, the abdomen, groin, and legs being least afiected. The raab may
occur in the mouth, pharynx, and larynx. Two days later the papules
become vesicular. The eruption comes out in one crop, and is therefore
never multiform in any given area of skin, as it is in varicella. Some of the
papules, however, may abort and not proceed to vesiculation. Each
vesicle enlarges, and by the sixth or seventh day has became pustular,
presenting in typical cases, unmodified by vaccination, a depressed centre

482 PfBEStA [j85S

which 18 held down by a bridle, a feature known as uinbilication. The next
da}' (eighth day) the bridle ruptureB, and each pustule becomes hemi-
spherical, about as large as a split pea, with an inflamed and indurated
base, and at this time considerable oedema of the skin is present. These
pustules gradually dry into scabs, which separate about the fift«enth to
the twentieth day, though in some situations, such as the scalp, forehead,
and sides of the nose, considerably later, leaving patches of congested
skin, and in severe cases a pitted cicatrix. The extent of the eruption
and the amount of inflammatory induration varies considerably. Some-
times only the face and wrists present a few spots; sometimes the nhole

Fls. M. — A mild eua of HODimD tasiola oaennlng In t. romui vonuin, nt. E£, who had been

vMdiiated two yeaie prevlomlj' and who prewnted three visible ciiatricai ol tlia prinur;
TicclnaUon. Initial ■ymptoma levere. Ho maon&axj fever. The luUior li Indebted
for tW* ohert to Dr- F. F. Ciiger.

body is covered. The eruption on the legs always presents a proportionate
retardation of development, since it appears laat in this situation. Con-
sequently, before certifying a patient as free from infection, the soles of
the feet should be carefully examined, and should the thick epidennis be
found to harbour any dried-up remnants of obsolescent pocks, these should
be carefully dug out and removed before the case can be regarded as free
from possible infection,

HoDinaD SxALL-POX, or Tarioloid (Fig. M), is the term applied to the disease
when modified bj previaoB vaccination. T%e primary fever and early ajmptome are
indiBtinguishable from the uuinodified form above described, and the emption appears
on the third day. Modified diSersfrom unmodified small-pox in five ways : (i.) There
is little if an; secondaTy (mppniative) fever; (ii.) certain portions of the eruption
abort and do not pan through all stages ; (iii.) as a oonsequence, several stages of the

{ 8M ] SMALL-POX 483

eruption may occosionoUj be seen on the same portion of skin ; (ir.) the geneni
emption may be very sMnty, and may consiat of not more than a dozen papules, which
may not even undergo vesioulation ; and (v.) the oonatitutional symptoms ate lesa

Varietiet. — It is sufficient to describe three varieties, according to the
severity o£ the disease, the severity of the symptoms corresponding very
closely with the character and extent of the eruption i (1) Mild or Discrete,
(2) Confiuenl, and {3) Malignant or Stemorrhagic. This form is very
severe, but, fortunately, not very common. In MalignaiU small-pox there
are hfemorrhages into and beneath the skin, and from most, if not all
of the mucous membranes, and death ensues early (Fig. 95).

.. — „ ._. . .._....__.. , » diitlnct Iroin those tweioJ confluent

■m»11-poi[ with liffmoTThngMi in the pwtuLea). — Patient unvacdnated. Deatb ocounod on
the nth (Lay. The vulons lacldenU are Bhown on the chart, lor which the author li indehted
to Dr, F. r. Calger.

Diagnosis. — In modem times, when nearly all cases of small-pox are
modified by vaccination, the diagnosis is not always easy, and the greatest
difficulty may be experienced in making a diagnosis even from acne.
There are three important diagnostic features ; (i.) Sudden advent of high
fever; (ii.) headache, backache, and vomiting at onset of the disease, of
which there should always be a history, even in the mildest cases ; and
(iii.) the shotty character of the papules.^ Measles is the disease which is
most often mistaken for variola in the early stages of the case, and there-
fore two plates of these diseases are presented side by side (Coloured Plates

484 PYREXIA [§355

1. and II.). Measles is distinguished by the redness of and the running
from the eyes, with other signs of catarrh, and the presence of Koplik's
spots on the buccal mucous membrane. The rash, too, is macular rather
than papular, and the individual spots as they increase in size spread out
in patchy coalescence. Varicella is distinguished by the inappreciable
character of the premonitory constitutional symptoms ; by the fact that
the temperature rises as the rash appears, instead of quickly subsiding ;
by the eruption coming out in a succession of crops, so that one portion of
skin may show several stages of the eruption ; by the rapidity with which
the rash passes through the successive stages of development ; and by the
vesicles not being preceded or accompanied by any shoUy induration. In
febrile roseola or lichen, the fever lasts only twenty-four hours, the efflor-
escence appears all over the body at once, and it does not go on to any
further stage. Pustular syphUide is chronic, and is unattended by any
marked pyrexia.

Etiology, — The malady is highly infectious, but its specific cause has
not yet been discovered. Guarriceri has described a protozoon as con-
stantly present in the epithelial cells of the small-pox vesicle, and this is
supported by Councilman. Its causal role, however, has not been so far
established. Children, and especially infants, are particularly prone to
the disease, and before the discovery of vaccination (a.d. 1776) it was a
cause of considerably more than half the infantile mortality in Great
Britain and other countries.^ The poison is conveyed through the air to
a considerable distance. Some believe it may be conveyed to a distance
of miles, but this is very doubtful. ^ One attack confers complete im-
munity in most instances ; authenticated second attacks are extremely
rare.

Prognosis, — Vaccination, — The case-mortality of small-pox in the
present day is about 37 per cent, amongst the unvaccinated ; about 5 or
6 per cent, amongst all classes of the vaccinated taken together ; and about
J per cent, amongst the properly vaccinated. The severity of the disease
seems to depend almost entirely upon whether the patient has been
recently and efficiently vaccinated.^ In the healthy and recently vac-

^ It is a fact of some interest that Warrington was the scene of an epidemic of
small-pox in 1773, and the death-rate from the disease in that year was 26*5 per 1,000
(211 deaths, and, reckoning five inhabitants to a house, 8,000 inhabitants), all the
deaths occurring in persons under nine years of age. — Dr. Thomas Percival, F.B.S.,
Phil. Trans., 1774, vol. Ixiv.

In 1892-1893 Warrington was again visited bv an epidemic, and the death-rate
was then I'l per 1,000 of the inhabitants, who haa at thisbt time only about 1 per cent,
unvaccinated persons among them.

^ This question has been very hotly debated, but in the author's belief there are no
definite evidences of small-pox being conveyed through the air to a greater distance
than a few yards. It is extremely contagious, and all the cases supposed to be due
to aerial spread can, if sufficient information can be procured, be explained by the
conveyance of contagion either from person to person, or through some mediate agency.
— Report on the m^rrington Small-pox Epidemic, 1892-1893. pp. 64-77. Appendix
to the Report of the Roy. Com. on Vaccination.

3 The figures from the Warrington epidemic, 1892-1893, are very striking. In the
infected houses there were 2,535 persons, and 2,223 of these persons had been vaccinated

1 855 ] 8M ALL-POX 486

cinated ifc is a comparatively trivial disorder, but in the uuvaccinated,
especially in infancy, it is one of the gravest diseases. The second factor
in the prognosis is the question of age; and the official records of the
unmodified outbreak in Warrington in 1773 show that of 211 fatal cases
1G6 were under three years of age. Alcoholism and plethora add to the
gravity of the disease. The greatest danger is on about the eleventh
day in the confluent form. As regards the varieties y the confluent, in
which the rash may come out on the second day, and is very abundant,
is much more dangerous than the discrete form. In the former the fever
does not subside on the third day, and there is a great tendency to hyper-
pyrexia and complications. True hsBmorrhagic small-pox is invariably
fatal, but if hsBmorrhage occurs uUo the vesicular or pustular rash, there
is a good chance of recovery. As regards untoward symptomSy the more
severe the primary fever in the unvaccinated, the more severe will be the
disease, but this is not necessarily so in the vaccinated ; profuse salivation
is a bad symptom ; the case is grave if there be no swelling of the skin
at about the ninth day, and still graver if the swelling goes suddenly
away ; convulsions and other complications are unfavourable.

Complications. — (i.) Acute laryngitis or oedema glottidis is a common
cause of death. Hypostatic congestion, pleurisy, empyema, erysipelas,
and pneumonia are apt to occur, (ii.) The heart may be affected with peri-
or endo-carditis ; but myocarditis and granular degeneration are more
common ; (iii.) ophthalmia and consequent destruction of the eye is
common in the East ; painless corneal ulcers may form and perforate ; and
(iv.), for the rest, the complications are the same as those of scarlet fever,
but nephritis is not so common.

Treatment, — It should be remembered that vaccination is capable of
modifying the disease even after exposure to infection, because the in-
cubation period of variola is twelve days and that of vaccinia only eight
days. Vaccination may, therefore, be performed with efficacy during the
first three or four days after exposure ; and every member of an infected
household should be vaccinated immediately the disease breaks out therein.
As regards therapeutic agents^ little is necessary in the Discrete form beyond
a mild aperient and salines. In the Confluent form stimulants are neces-
sary, and we must watch for complications, and meet them as they arise.
To this effect the eyes should be examined in a good light daily. If much
salivation be present, it may lead to suffocation. The patient should be
put into a warm bath and kept there for a considerable time. For sore
throat use gargles ; for oedema glottidis, inhalations, or tracheotomy may

in infancy. Among these latter 521 (23*4 per cent.) were attacked, and 27 died, so
that the case-mortality among them was 5*2 per cent. There were in the infected
houses 107 unvaccinated persons, of whom 60 (56'lper cent.) were attacked, and
21 died, giving a case-mortality of 85*0 per cent. The figures also showed that in
proportion as the vaccination had heen more efficient, the severity of the disease was
less. Finally, among all the 667 cases which occurred in this epidemic, not one had
been vaccinated or revaccinated within seven years of the attack. — Appendix to the
Report of the Roy. Com. on Vaccination, 1894.

486 PYREXIA t§«^

be necessary. Many devices have been contrived to prevent scarring by
the eruptions, such as powdering with zinc and starch powder, or with
pulv. cretfle aromaticus, with a small quantity of disinfectant, or laying
on lint soaked in glycerine and water, with a drop or two of carbolic acid.
But all of these are of very doubtful benefit. There is, however, a method
which promised to be really efficacious — namely, placing the patient in a
room from which all but the red rays of the spectrum are excluded by
pasting red paper over the windows. The red light treatment has been
reported on very favourably by Finsen, but has not proved very successful
in this country. Hygienic Treatment is given in §§ 389 et seq.

The Preventive Treatment of small-pox is accomplished in the present
day by three means — disinfection, isolation, and vaccination. Concern-
ing the first two see § 389 ; for evidence of the efficacy of vaccination in.
the prevention and modification of small-pox see p. 484 and below.
InoaUation used to be practised because it was found that the inoculated
disease was milder, and gave just as much immimity from a second attack.
Out of 20,000 inoculated by the brothers Sutton not one died. It was,
however, declared illegal in 1840.

§866. Vacdnia. — Vaccination is the production in a person of the
disease called vaccinia, by inoculating him with the lymph taken from the
udder of a cow or calf sufiering from that disease. It was noticed in 1769
by a German that people engaged in the milking of cows were exempt from
small-pox. Jenner, in 1775 and 1776, placed the subject on a scientific
basis, and ascertained that the inoculation of a human being with the
lymph taken from the imbroken vesicles on the udder of a calf suffering
from vaccinia protected that person from small-pox. He was also the
first to inoculate this disease (vaccinia) from person to person by taking
the lymph from the vesicle on the arm which had matured on the eighth
day after inoculation. Vaccination was made compulsory in 1853. In
1897 this law was repealed in response to an outcry among the public that
syphilis and (?) other diseases could be conveyed from person to person
in this way. Syphilis certainly has, in rare instances, been conveyed by
arm to arm vaccination ; but by using calf-lymph this is entirely obviated ;
and all public vaccinators now use lymph direct from the calf. Anyone
who now goes before a magistrate and solemnly declares that he has
"conscientious objections" to vaccination can procure exemption for
himself and his children from compulsory vaccination.

RtUes for Vaccination, — Calf-lymph is now universally used in Great
Britain.^ The best method is that of scraping the cuticle with a blunt-
pointed lancet. The lancet should be kept scrupulously clean, and passed
through a fiame before using. The doctor's hands should be clean, and
the arm of the patient should be washed with soap and water before
vaccination.

^ If human lymph is employed, it should bo taken from a child, not an adult, and
the child shoula be in good health, and free from any evidences or history of S3rphili8.
The lymph should be taken from a vesicle before it becomes opaque, and before the
areola has formed. It is better to vaccinate from arm to arm than from stored tubes.

S 807 ] MEASLSS 48t

The Phenomena of Vaccination, — There are no sjrmptoms for the first
two days. On the second or third day a slight pimple, on the fifth day a
bluish-white cupped vesicle appears, and on the eighth day (the same
day of the week as that on which the operation was performed) the vesicle
becomes matured. It should never become purulent, but the areola in-
creases during the next two days. The contents then become cloudy,
and after the tenth day they dry up ; the scab falls on the fourteenth or
fifteenth day, leaving a pitted cicatrix.

The inquiries which the author made on behalf of the Royal Commission
on Vaccination into the Warrington Epidemic {loc, dt) went to prove
(1) that efficient primary vaccination offers absolute protection against
infection for the ensuing five or six years, and relative protection (gradually
diminishing) for a considerable time ; (2) that primary vaccination lessens
the severity of the attach of small-pox if contracted during the ensuing
twenty or thirty years ; (3) that revaccination affords absolute immunity
from attach during the ensuing five or six years, and relative protection
for the rest of life ; and (4) that if everybody were vaccinated in infancy
and again at twelve and twenty-one, small-pox would be exterminated.

§357. V. Measles may be defined as an infectious febrile disease
attended by catarrh of the respiratory passages, and by an eruption of
minute elevated papules aggregated into irregular and often crescentic
groups.

Symptoms, — (1) After an incubation period of seven to fourteen days,
usually ten or eleven, the pyrexia (Fig. 96) comes on abruptly, though not
so suddenly as in scarlet fever, rising to 102° or 103° F. on the evening of
the first day. The next day it usually declines a little. When the rash
appears on the fourth day it rises again, remains up imtil the sixth day,
and then falls by crisis. (2) The fever is attended by symptoms of coryza
— for which, indeed, the case may be mistaken if the temperature be not
very high. There are profuse lachrymation, running of the nose, and
bronchial catarrh, the larynx and bronchi being specially involved. The
fauces are sore, and mottled with redness, but not much swollen.
(3) Eoplik has described spots, which appear from one to three days
before the skin rash on the buccal mucous membrane opposite the bicuspid
or molar teeth, and just within the angle of the mouth. They are not
easy to see, and require a good light, when they give the appearance of a
white stippling on a slightly raised reddened base. They occur in more
than 90 per cent, of all cases, and, consequently, lend great help to the
diagnosis in the early stages. (4) The eruption appears on the third or
fourth day (Coloured Plate II.). It consists of red, raised, well-defined
fiat papules, discrete at first, but afterwards tending to coalesce into
irregular-shaped patches. The colour is a reddish-brown, disappearing on
pressure. The spots first appear on the ^ooe behind the ears and side of
the neck, where they are most abundant, and then pass downwards. Each
papule reaches its maximum in about twelve hours to twenty-four, and
then feels soft and velvety, thus differing from the early stage of small-pox

488 FYSBXIA tS»87

papules. They soon begin to recede, and at the end of forty-eight hours
to fade. By the e^hth or ninth day the eruption of measles has com-
pletely disappeared, except that a brownish mottling of the skin may
nmain foi some time after. Occasionally the macules become petechial.
Sometimes the eruption suddenly disappears — the result of some internal
complication, not, as Is often supposed, the cause. The catarrh goes on
incieaMug during the development of the ra3h,and they subside together
about the sixth to the eighth day, when convalescence commences. Sl^ht
desquamation of minute flakes, chiefly on the face, neck, and arms, occurs
sometimes.

The Yarietia are less well defined than in scarlatina. The malignant
or hemorrhagic variety, now, fortunately, rare, is very severe, and is

r the lutbor'i cure). Typical chart. Ths viilont
mn upon the chart.

attended by petechia and the typhoid state. The rash or catarrh may be
absent in exceptional cases.

The Diagnosis from a severe " catarrh" in the absence of Eoplih's
spots, is very difficult until the eruption appears. Varu^ often preaente
a difficulty, though the absence of catarrh, and the presence of pain in the
back and vomiting, aid us considerably in diagnosing variola. The
diSerencea between the rashes are referred to above. Erythema Muili-
/orme is somewhat like measles, but is recognised by the absence of catarrh
and pyrexia. That set up by the injection of an antiserum is especially
suggestive, and may lead to temporary confusion. The paramount
importance of " Koplik's spote " in the early diagnosis of measles can
hardly be exaggerated. For the diagnosis of German Measles see S 358.

The eruption, whith is very plentiful, is eighteen hours old isei'ond day of rash).
Note the evidences of coryza in the eyca and nose.

Drawn tram nnttm by iliti Mnbtl Onen.

5 858 J MEASLES 489

Etiology. — Measles is essentially a disease of childhood, and few escape
It is endemic in England, and outbreaks occur from time to time. The
seasonal prevalence is in the spring and winter. The essential cause is
probably a living organism, which has not yet been identified. It is con-
veyed chiefly by the breath and nasal mucus. Unlike scarlatina, it is as
contagious before as after the eruption has appeared, and its infectivity
disappears more rapidly. One attack confers relative immunity ; second
attacks are less common than in scarlatina, the majority of so-called
second attacks being probably Rotheln.

Prognosis, — Measles is not as a rvde a serious disease in itself, except in
infancy. The case-mortality in an outbreak does not often exceed 2 per
cent., though it may be as high as 10 or 12. The most important deter-
mining factors are poverty and the proportion of very young children.
The chief danger of the disease rests in the complications and sequelsB
which may attend even the mildest case of measles. The prognosis is
bad in proportion to the severity of the pyrexia and pulmonary symptoms.
Strumous or weak children suffer most. Convulsions late in the disease
are of grave significance. The most important and most common compli-
cations are bronchitis, broncho-pneumonia, pneumonia, and collapse of the
lung, and diarrhoea, especially in the summer months. Phthisis is a recog-
nised sequela ; it follows measles and whooping-cough more frequently
than any other febrile disease. Catarrhal laryngitis, diphtheria, and
laryngismus also occur. In all cases of measles with sudden aggravation
of fever and no apparent cause, the presence of acute otitis media may be
suspected. Cancrum oris is not unconmion, beginning as an ulcer on the
internal surface of the cheek, surrounded by intense inflammation. Soon
a black slough appears, followed by perforation. Occasionally it starts
in the gums in the neighbourhood of a carious tooth, and the alveolus may
be involved in the necrosis. Gangrene may occur in other parts, such as
the genital organs. Other complications are ophthalmia, stomatitis, and
rhinitis. Caseous bronchial glands are common sequelse.

Treatment, — A hot bath may be given at the onset. Remedies are
directed against the bronchitis, the most useful being ipecacuanha and
liq. ammonisB acetatis, F. 53 (General Treatment, see §§ 389 et seq,). The
early application of a jacket poultice in the case of infants with bronchial
involvement will often work wonders.

§ 858. VI. Bdtheln, or German Measles (Synonyms : Rubella, Rubeola, Epidemic
Roseola, Hybrid Measles), may be defined as an aoute contagious disease, characterised
by sore throat, oatarrii of the respiratory passages, and an eruption of the skin,
consisting of minute pinkish-red spots, which afterwards become confluent. Clinically,
it may be said to represent a combination of measles and scarlatina, giving rise to a
diffuse redness of the surface. Undoubtedly, many so-called cases of Rotheln are
identical with measles.

The Symptoms vary somewhat in different epidemics. (1) After a period of incu-
bation, variously stated to be from seven days to two or three wooks, but more often
ten to seventeen days, the temperature rises to 100°, 101°, or 102° F. This is accom-
panied by sore throat and coryza. Usually the glands in the neck and elsewhere are
swollen, the most characteristic being the concatenate and occipitsil groups. Tender

490 P YREXIA D §§ 869> MO

swelling of the cervical glands is sometimes present several days before the rash
appears, the patient often complaining of " stiff neck/' which he usually ascribes to
having sat in a draught, or some such reasonable explanation. When the eruption
comes out, the other symptoms are considerably aggravated, but the whole attack
rarely lasts as long as a week. The rash may be the first indication of the disease,
as the primary fever is sometimes so slight, or it may be entirely absent. (2) Tho
eruption is sometimes delayed imtil the third or fourth day of attack, and consists
of minute round or oval rose-red spots, varying in size from a pin's head to a pea,
very slightly raised, never papular. The rash at the outset is like that of early measles.
In a day or two it becomes confluent, or nearly so, and the whole skin presents a
scarlet hue, so that the case may be mistaken for scarlatina. The eruption first
appears on the face, and at the end of twenty-four hours the whole body is involved.
It lasts from two or five days, and the severity of the attack is in direct ratio to the
duration and severity of the eruption. It is sometimes followed by slight desqua-
mation. The disease has to be diagnosed from scarlatina, in which there is no catarrh,
and no ** measly ** eruption at the beginning of the attack, but the tongue will show
the ** strawbeny " character. In meades one should look for " Koplik's spots,"
but there are no enlarged glands, no special involvement of the tonsils, but little sore
throat, and no extensive confluence of tho rash. In non-specific roseola (rose rash),
there are no catarrh and no sore throat.

Etiology. — It is mainly a disease of childhood, but sometimes attacks adults. It
is not so contagious as either scarlatina or measles (Murchison). One attack confers
immunity.

Prognosis, — It is a more trivial disease than measles, tho result being always
favourable.

The Treatment is like that of measles.

§ 869. VII. Dengue is an infectious fever, of tropical and subtropical climates
which is due to the inoculation of an unknown virus by the bite of CuLex faiigans.
The incubation period of dengue is three to six days. The fever is of a sudden onset,
and ranges from 102^ to 105^ F. It is accompanied by intense headache, with
extremely severe pains in the joints or limbs, much aggravated by movement. This
primary fever lasts about forty-eight hours, and subsides by crisis. At this stage
the skin may be covered with a bright red flush chiefly about the face and neck.
Haemorrhage from the nose or stomach may also occur. During the next one to
two days there is an interval of apyiexia, with freedom from pain. Occasionally this
interval is absent. Then the secondary fever appears, with a return of the pains in
the limbs. Both, however, are less severe than in the primary stage. A universal
mottling of the skin, starting on the hands, somewhat resembling measles, though
never papular, may accompany the secondary fever. As it subsides in a day or two,
slight branny desquamation occurs. There is leucopenia during the fever.

Diagnosis. — ^Dengue is known from scarlet fever, which is rare in the tropics, by its
being rarely associated with sore throat or enlarged cervical glands, by the severe
articular pains, and by its occurring in hot weather, and, later, by its characteristic
temperature. Acute rheumatism is rare in the tropics, has no rash, and has profuse
sweats. Measles has coryza and Koplik's spots ; influenza has no rash.

Prognosis. — ^As regards life, the prognosis is excellent ; the case - mortality is
extremely smalL Death rarely, if over, occurs ; if so, it is from such complications
as weak heart or hyperpyrexia, in the enfeebled. In most cases the acute symptoms
have passed off in eight days. Some have painful joints and crippling for some time
after the fever has gone. The disease confers immunity for some little time.

The Treatment does not differ from the ordinary hygiene necessary in fevers. Tho
patient should be kept in bed. For the pain in the limbs, belladonna, antipyrin, and
even morphia may be given. The subsequent ansemia and enfeeblemont are some-
times troublesome. Prophylactic treatment is that for malaria, with the exception
of the use of quinine.

§ 860. VIII. Typhoi (Synonyms : Contagious Typhus, Exanthematic Typhus,
Hospital, Gaol, and Ship Fever) may be defined as a contagious fever, lasting fourteen
days, with an eruption on the skin consisting of subcutaneous mottlings and petechial
spots, with a great tendency to the typhoid state. Its disappearance from our midst

§8e0] TYPHUS 491

is a good illustration of the triumphs of hygiene. It is due to a highly contagious
specific poison, which can be propagated only where overcrowding, deficient ventila-
tion, squalor, and destitution exist. As these conditions have disappeared, typhus
has gradually died out, though it is still occasionally met with in Glasgow, Liverpool,
parts of Ireland, and other places where the poor are crowded into back-to-back houses.

Symptoms, — (1) After an incubation period, which varies considerably, but is
rarely longer than twelve days, the temperature rises rapidly for two or three days
to 103° to 105° F., or more, at which it remains until the fourteenth day. It starts
somewhat abruptly with chilliness, rarely with rigors. There is severe headache
and extreme prostration, so much so that on the second day the patient is unable to
walk or stand. Drowsiness is common, and there is a typical aspect of heavy stupidity.
At the end of the first week headache gives place to delirium, and this is followed by
drowsiness and coma. The temperature continues to rise until the seventh day, and
then falls slightly during the ensuing week, and usually ends by crisis on the fourteenth
day. (2) The spleen is enlarged and tender. (3) The eruption appears usually on
the fourth or fifth day, first on the back of the hands, arms, folds of axillse, and in
front of the chest and abdomen. It has usually two elements, which vary in their
proportion : (a) Subcuticular mottling, certain portions of the skin appearing hyper-
eomic, with fading margins ; (6) purple, or brownish-rod spots, having a definite but
irregular outline, varying in size from a pin's head to three lines, very slightly elevated
at first, and in the course of two or three days becoming petechial, so that they will
not disappear on pressure. One attack usually confers immunity. The patient ceases
to be infectious, it is said, the second day after the evening temperature is normal.

Diagnosis. — (1) Typhoid fever was originally confused with typhus, and it is chiefly
owing to the observations of Sir William Gairdner and Sir William Jenner that they
are now differentiated. Typhoid differs from typhus in (i.) the insidious onset ;
(ii.) the course of the temperature ; (iii.) the different eruption ; and (iv.) the diarrhoea
and pea-soup stools. (2) In measles the eruption resembles the typhus spots, and
appears at the same date, but in typhus it docs not involve the face, it is never preceded
by catarrh, is never papular, and becomes petechial. (3) Some malarial fevers present
considerable difficulty, but they have no eruption. (4) Urcsmia and other causes of
coma may be mistaken for it. (5) Pneumonia, meningitis, and other causes of the
typhoid state may be confused with typhus. (6) Epidemics of plague have been
confused with typhus, but the parotid swellings in plague occur earlier, during the first
week.

Etiology. — ^The disease is met with at all ages, but is more dangerous in middle and
advanced life. It is due to a specific contagium which has never yet been isolated.
Doctors and nurses frequently contract it ; Dr. Charles Murohison, who did so much
for the study of this and other fevers, contracted typhus twice, and thus incurred the
heart disease of which he died. The disease is associated with overcrowding, deficient
ventilation, and personal squalor. It is thought to be conveyed by lice or bugs.
The malady is predisposed to by a general debility, and it is therefore commoner in
times of famine and distress.

Prognosis. — Case-mortality, 10 per cent. : between the age of fifteen and twenty-five,
4 per cent. ; over fifty, 60 per cent. Thus the ago of the patient greatly influences the
mortality. Typhus is always a serious disease, especially in the plethoric and alco-
holic. It terminates fatally in three ways : (i.) Degeneration of the cardiac muscle,
which is a very common accompaniment of the disease ; (ii.) coma, from the toxic state
of the blood ; or (iii.) asphyxia or hypostatic congestion of the lungs. Untoward
83nnptom8 are (i.) weak, irregular, or intermittent pulse, or other indications of cardiac
weakness ; (ii.) an abundant rash, with high fever ; (iii.) early and protracted cerebral
signs or protracted hiccough ; (iv.) all complications, especially pulmonary. Of the
complications and sequelcs, (i.) the pulmonary are the worst, especially broncho-
pneumonia and hypostatic congestion of the lungs ; oedema glottidis and pleurisy are
less common. Other complications are (ii.) hyperpjrrexia and meningitis ; (iii.)
femoral and other thromboses ; (iv.) gangrene of ^e extremities from embolism, bed-
sores, and pysemic abscesses ; (v.) cardiac weakness, which may remain for a long
time, on accoimt of the granular degeneration of the muscle ; (vi.) post-febrile mania ;
and (vii.) paralysis of various parts.

492 P TREXIA [ §§ 861, 868

Treatment. — ^Hygienic treatment is eseential (§§ 386 et seq.), especially free ventila-
tion. Therapeutic treatment is chiefly symptomatic, and for this reason stiychnine
is useful. It is sometimes the practice to give an emetic at the outset. Mineral acids
may assist the digestion. Stimulants in most cases are not necessary, but they must
be given if the pulse is weak or irregular, or if the extremities are cold.

§ 861. Anthrax, or Malignant Pustule (Synonyms : Woolsorters' Disease, Anthrac-
ffimia. Splenic Fever — under which term the disease is registered in the Registrar-
Grenerars returns — Charbon, Carbunculus Verus). The primary lesion consists of a
solitary vesicle at the seat of inoculation. As the base of this becomes transformed
into a central slough, the contents become hardened, and around this a zone of vesicles
arises. Pasteur showed that it is due to the anthrax bacillus, a relatively large
organism which was one of the first to be isolated.

This disease, which has a marked and prolonged vesicular stage, is most usuf^lly
situated on the dorsum of the hand or arm, occasionally on the face ; 82 per cent,
of the cases show pustules on the head or neck. It affects woolsorters, furriers, felt-
makers, ragsorters, and others who come in contact with animals or their hides or
fur ; 40 per cent, of the cases in British leather- workers are due to handling Chinese
or East India goods. No case has been traced to wet-salted hides. The incubation
period is twenty-four to seventy-two hours. First a papule forms at the seat of
inoculation, which rapidly enlarges, and becomes on the second day a vesicle, with
serous or haemorrhagic contents. On the third day this bursts, leaving a raw exuding
surface, which, on the fourth day, turns to a dry black slough, surrounded by a zone
of intense inflammation slightly raised above the surface. Upon this inflammatory
zone there appears, also on the fourth day, a characteristic ring of small red vesicles.
The oedema extends around, and the lymphatics and the glands inflame. The pain
is usually very slight, and no pus forms until about the tenth day, when the slough
begins to separate. The constitutional symptoms vary considerably, and bear no
proportion to the local mischief. The pyrexia may be so slight as not to interfere with
the patient's ordinary avocation, and it may not come on until some days after the
local signs. Usually, however, it is severe, comes on early, and soon assumes a typhoid
character.

Intestinal and Pulmonary types are also described, according to the method of infec-
tion. In the former intense vomiting and diarrhosa occur, with great prostration and
cramps, with, in some cases, cyanosis and dyspnoea, and towards the end convulsions
and spasms. The spleen is enlarged. In tho latter, which is caused by inhalation of
diseased wool or hair {wocUortera' disease), there are urgent dyspnooa, and pain in the
chest of sudden onset. The temperature rises to 102° or 103° F., and death may occur
with profound collapse in twenty-four hours. Sometimes delirium and convulsions,
or diarrhosa and vomiting, occur.

Diagnosis. — It may have to be diagnosed in the first place from the sting of an
insect, from various conditions which lead to solitary vesicles or bullae on the second
day, from erysipelas (if on the face), lymphangitis, and other causes of oedema. The
occupation of the patient assists us, but a diagnosis may be made by examining tho
serum or secretion of the sore, stained by Gram's method (Chapter XX.), under the
microscope. The bacHlus anthracis, which is tho cause of the disease, is thus readily
discovered.

Prognosis, — ^The mortality varies with the position of the primary lesion, being
40 per cent, when this is situated on the neck or face, and 12 per cent, when situated
Isewhere.

Treatment — ^The local lesion should be freely excised if seen early, and the wound
irrigated continuously with carbolic lotion (I in 20). The lotion may also, with
advantage, be injected into the tissue surrounding the part, and repeated every four
hours, due care being taken to watch for carbolic poisoning (carboluria, etc.). The
patient's strength must be supported. Sclavo has prepared an anti-anthrax serum,
which is still on its triaL Kecent reports (191 1 ) as to its value have been for the most
part favourable.

§ 862. Olanders (Synonym : Equinia) may be defined as a contagious febrile disease
attended by a discharge from the nostrils, and sometimes an eruption on the skin,
due to the inoculation of the bacillus mallei, in a person attending to Hobsks affectod

§868]

CONTINUED PYREXIA

493

with the disease. The eruption, which only occurs in Acute Glanders, oonsistB of
a general erythema, on which a crop of pustules of hemispherical shape appear in the
course of a few days or hours. They vary in size between a lentil and a florin. There
are also nodules of granulomatous material in the subcutaneous tissue and muscles,
which usually suppurate, leaving large foul ulcers. The other symptoms are (i.) a
copious discharge of viscid, semipurulent matter from the nostrils ; (ii.) pains in the
limbs and joints ; and (iii.) high fever, with rigors and prostration, passing on to the
typhoid state.

In Chronic Glanders (Farcy) the pyrexia and constitutional symptoms are absent,
and the cutaneous eruptions (erythema, pustules, and nodules which leave ulcers and
sinuses). The discharge from the nose may be the only sign.

Diagnosis, — ^The pustules of acute glanders resemble those of variola, but they are
larger, and not umbilicated, and the temperature in glanders does not fall when the
rash — in those cases which present a generalised pustular (-ruption — comes out. ^ The
pain and swelling of the joints and limbs bear some resemblance to acute rheumatism,
and still more to pyaemia. The reaction to mallcin may assist.

Treatment — Vaccination with small doses of dead bacilli is advocated, and has been
tried in a few cases. At present the disease is extremely fatal. In Farcy or Chronic
Glanders the death-rate is 40 or 50 per cent. Iodide of potassium, aconite, mercury,
iron, arsenic, and strychnine have all been tried, and good results have accrued from
the injection of small doses of mallein.

OROVP II, CONTINUED PYREXIA.

§ 863. In this group the pyrexia tends to assume a continued type
— i.e., it runs a continuous course except for the slight normal diurnal
variation (§ 347). This group is distinguished from Group I. by the
absence of an eruption during the first four days of the illness. It is dis-
tinguished from Group III. mainly by the course of the pyrexia, though
aberrant types of one group are found in the other.

Rocky Mountain Fever and some of the other fevers rare in this
country have an eruption which develops usually after the fourth day.

Common,

1, Enteric fever
II. Diphtheria

III. Influenza . .

IV. Rheumatic fever, pneu-

monia, and various
other inflammatory dis-
orders, usually attended
by local signs . .
V. Whooping cough . .
VI. Mumps

Rare in this Country,

364

VII.

Glandular fever . .

§ 369a

365

VIII.

Plague

§ 370

366

IX.

Undulant fever . .

§ 371

Yellow fever

§ 372

Epidemic cerebro - spinal

meningitis

§ 373

XII.

Relapsing fever . .

§ 374

367

XIII.

Thermic fever. Rocky

368

Mountain fever, Kala-

369

azar, and other fevers
rare or unknown in this

country

§ 375

Enteric Fever, which may be taken as a type, may in exceptional oases present no
other symptoms than the characteristic pyrexia. The rash, when present, may be
ill-marked, and does not appear till the second week of the disease. In Diphtheria
there is the characteristic throat lesion ; in Intlitbnza there are pains in the limbs

^ The author once notified a case of this kind as small-pox, and the case passed as
such through the hands of two of the most experienced medical officers of tne Metro-
politan Asylums Board, the mistake not being cleared up until after death, and a full
investigation had been made of the circumstances under which the disease arose. It was
then ascertained that the patient was a stableman, attending on glandrous horses.

494 PYREXIA [9884

ftnd ft mora sudden advent ; in Pbhtpssis tho eharaeUrislic cough ; and in Mumps the
paroUlit. Various HiCBoeic Ekactions may aid us in tho diagnosis. Cholbba
(} 220) and Dysbitebv (i 219) might also be inoludod in tiiis group, but the pyrexial
dUturbanco is quite a subordinate feature coniparod with the intestinal manifestations.
Di. Cabot {loe. eit.) analysed 7S4 cases of fever lasting two weeks or longer without
dropping to normal, and found that 90 per cent, were oases of enteiio fever (586),
sepsis (70), or tuberculosis (M). Under " sep^s " ha included all forms of B.5ptic
coatatnination of tha blood-stream, as by wounds, abscesses originating from tho
appendix, gall-bladder, genito-urinary tract, or alimentary canal or empyema (J{ 307
and3S4).

It was formerly the custom to speak of Enteric Fever, Typhus Fever (Group I.).
Relapsing Fever, and Febrioula, as the " Continuud t'evoa of Groat Britain." Of
these practically only tho first stiil piovailB amongst us. Fobricuia is gensially
identical with onlerie. Bolapsing fovor has only occurred in times of famine, and
Typhus has disappoaied with imptovad hygione amongst tho massoH.

§ 864. Enteric or Typhoid Fever may bo defined aa an acuto specific
fever of about three or four weeks' duration, with a tendency to diarrhcea
and the typhoid state, often attended by succeBaive crops of rose-coloured

Fig- BT.— ENTBBtO FiVBR (typloU chartl.— HsnTj' H , tot. E£ (under the aatbor'i ears) n* Id

hnpltal wbon he developed the enterii: fever. There was apathetic mental caadition. gnat
(eellDg or illneas and beadtube, watery pea-uup atoole, SDil bronchial catanh. The chart
■bows the continued cbaracter of the pyrexia Jd tbe second and tUrd weela, with gndnally
IncTeuiQR remlulons in tbe fourth and Bfth weeks.

spots, and due t« a specific micobe (the typhoid bacillus of Eberth, see
Coloured Plate IV. and Fig. 109). A characteriatic ulceration of Beyer's
patches occurs.

Symflotna. — (1) The period of incubatiou is usually about ten days,
but it may be shoTter or longer. The onset is insidious, differing in this
respect from the fevers in Group I. The most important early symptom
is headache, otherwise there are simply malaise and lassitude, usually
with constipation, and perhaps slight abdominal pain. The typical
typhoid chart (Fig. 97) is the most characteristic feature of the disease,
and imtil the discovery of the Widal reaction we were mainly dependent
upon this for the diagnosis of the malady. In the firgt week it ia " ladder-
like," gradually rising with diurnal remissions until it reaches, about the
end of the first week or ten days, its highest point (103° to 105" F.). During
the second stage, which may last a week or more, it remains continuously

§864] ENTERIC OR TYPHOID FEVER 405

high, the diurnal remissions often being no more than those which are met
with in health. As the disease progresses, these daily remissions become
gradually more and more marked. During defervescence, usually about
the fourth week, first the morning temperature, and then the evening
temperature, gradually become normal. These features are so constant
as to afford a means of detecting the stage which a case has reached.
Convalescence may be said to be established when the evening temperature
has been normal for two successive nights. (2) Some diarrhoea is usually
present after the first week — at least, in cases of moderate severity — and
the stools are of a characteristic pea-soup or yellow ochre colour. This
feature is of very little value as a means of diagnosis, while a patient is on
milk diet. In about half the cases there is no diarrhoea throughout, and
the bowels are confined, but these include the large proportion of mild
attacks ; complete absence of diarrhoea is exceptional in cases of any
severity. (3) The spleen is generally tender and enlarged throughout the
disease, being frequently palpable even without the patient taking a long
breath. T3nnpanitic distension of the abdomen is common, especially in
the second and third weeks, and there is often pain and gurgling on pressure
in the right iliac fossa, though great care should be used in attempting to
elicit this symptom, as the intestinal wall is thinned by disease. (4) The
eruption generally commences to come out about the seventh to twelfth
day (average, tenth) in successive crops ^ of small rose-coloured lenticular
spots, slightly elevated, soft, and disappearing on pressure. Each spot
lasts about three or four days. They are never petechial. They are
chiefly met with on the abdomen, sometimes on the rest of the trunk, very
rarely on the face or limbs. The number of these spots varies considerably,
but they are rarely abundant. They may be very small, and thus be
overlooked or mistaken for flea-bites. (5) Malaise is a very constant
feature from the outset, and it is for this symptom that we are generally
consulted. Lethargy is very marked, and gives rise to the aspect {fades
typhoaa), which is fairly characteristic ; the drowsiness deepens to semi-
stupor, and in severe cases the typhoid state eventually supervenes.
The tongue is first covered with a thin white fur, the edges and tip being
red ; in the second week the fur clears off, and the tongue becomes glazed
and dry, or red and smooth. Shallow transverse fissures are often seen
on it. Sordes collect on the teeth. Several varieties of the disease have
been described, but they are not of much importance. Occasionally the
disease commences quite suddenly, with symptoms of great severity.
The " ambulatory " form is so called because the patient is able to keep
about while suffering from it. Perforative peritonitis may be its first
manifestation.

Diagnosis. — Until recently the diagnosis of typhoid was often a matter
of excluding all other possibilities, and even then was largely a matter of
conjecture. But at the present time we have a valuable test in Widal's

^ This fact may be revealed by enclosing each of the spots which appear on one day
by a circle, next day by a triangle, and so on, by a nitrate of silver paint or aniline ink.

496 PYREXIA [§S64

reaction, for which purpose a specimen of the patient's blood must be
procured and sent to a laboratory (see Chapter XX. for method). The
diazo test is also of service, though not so certain. Undoubtedly many
slight cases of typhoid are overlooked or spoken of as Febricula {vide
infra). Slight cases are also apt to be mistaken for Influenza, which,
except for the pulmonary symptoms, the more sudden advent, and brief
duration, much resembles mild typhoid. The other specific fevers in this
group may also have to be excluded. In most cases of typhoid there
appears early in the disease a generalised bronchial catarrh and hypostatic
congestion of the lungs, and nothing is commoner than to mistake enteric
fever, in its early stages, for pulmonary congestion or bronchitis, and
severe cases may be mistaken for pr^eumonia. These pulmonary disorders
should be recognised by the relative absence of the prostration, and the
diarrhoea, enlarged spleen, etc., of enteric. In severe cases of typhoid,
early delirium may occur and suggest meningitis ; but the latter is recog-
nised by (i.) the retracted abdomen ; (ii.) the irregular and sighing respira-
tion appearing early in the disease and (iii.) the headache persists longer,
and may concur instead of alternating with the delirium (Miuohison) ;
signs of intracranial pressure also supervene, such as ptosis, squint, optic
neuritis, and other local paralyses. Acute Miliary Tuberculosis is a
disease which sometimes so closely resembles enteric that, as Niemeyer^
remarks, they can only be differentiated in the dead-house. The positive
signs of typhoid are wanting, and the presence of tubercle is suggested by
(i.) the intermittent character of the temperature and its prolonged
course ; (ii.) the lung symptoms are much more marked ; (iii.) the rapidity
of the breathing is out of proportion to the other signs of illness ; and
(iv.) the pallor and lividity of the face and the rapid emaciation are also
more prominent features. Malignant endocarditis is recognised by (i.) the
intermittent character of the temperature (usually), often with rigors, and
(ii.) the cardiac signs. Pycemia is differentiated by the wide range and
irregularity of the pyrexia (§ 383).

Etiology. — Enteric fever is now known to be due to a specific microbe
which has been isolated. All matters which the patient discharges from his
stomachy botods, and bladder are infective. Most epidemics are due to the
contamination of the water-supply by sewage. The disease has also been
traced to the eating of oysters ^ and other shell-fish, to ice-creams, and to
the milk supply. To produce the malady the microbe must be introduced
into the alimentary canal ; thus, nurses and friends contract the disease
by handling the bed-pans and sheets, or any other articles which have
been contaminated by the fsBces and urine. The excreta become more
virulent after standing from twelve to twenty-four hours. The malady
is most prevalent in the autumn and early winter ; and Pettenkofer has
found by several years' observations that typhoid outbreaks are favoured

1 ** Textbook of Practical Medicine." This was before the discovery of bacillus
and Widal's reaction. .
a Sir William Broadbent.

§ S64 ] ENTERIO OR TYPHOID FEVEB 497

by (i.) a rapid falling (after a rise) of ground water — that is to say, a well-
aerated moist soil ; (ii.) a certain temperature of the earth ; and (iii.) pollu-
tion of the soil by animal impurities. One attack does not necessarily
confer immunity, as second attacks are not very uncommon. The malady
is chiefly met with in young people between ten and thirty years of age.

Prognosis, — The case-mortality varies in diflEerent epidemics from 5 to
20 per cent. The prognosis is more favourable in the young. It is always
a serious disease on account of the numerous complications, prolonged
course, and its exhausting nature. The usual duration is about three or
four weeks, though it varies from ten days to six weeks even without
relapses, which are by no means infrequent. Untoward Symptoms. — The
height and the continued character of the fever are the best guides to the
severity of the attack. Many of the fatal issues would be avoided if it
were remembered that slight attacks require just as much care as severe
ones, being liable to be attended by haemorrhage and perforation if the
patient does not remain at rest. The prognosis is grave when the fever
remains at about 104° F. throughout the second week, and especially if
the diurnal remissions do not increase, as they should do, in the third
week. It is also grave when there are vomiting, except at an early stage,
urgent diarrhoea at any time, severe tympanites, or hsemorrhage. A sudden
fall in the temperature suggests hsemorrhage or the occurrence of peri-
tonitis. The most common complications are : (1) Those of the lungs,
and, as previously mentioned, bronchial catarrh and hypostatic conges-
tion are practically symptoms of the disease. Pneumonia and pleurisy
also occur. (2) Haemorrhage, due to the ulceration of Peyer's patches,
occurs in 8 or 10 per cent, of the cases. (3) Perforation. (4) Peritonitis,
either local in its distribution, when it is due to the spread from the ulcera-
tion, or to perforation, is a frequent complication, and it is sometimes
peculiar in being latent — that is to say, unattended by the pain which is so
characteristic of that disorder. Its occurrence can then only be recog-
nised by (i.) vomiting; (ii.) great aggravation of the already existing
prostration ; (iii.) a small rapid pulse (120 to 140) ; (iv.) immobility and
distension of the abdominal walls ; and (v.) a sudden fall of the tempera-
ture ; (vi.) the fades Hippocratica. (5) Other complications are throm-
bosis of the femoral vein, local suppurations and inflammations, such as
parotitis, periostitis, pericarditis, cholecystitis, cancrum oris, and laryngeal
ulceration. As sequelw multiple abscesses, dementia, peripheral neuritis,
phthisis, and miliary tuberculosis may occur.

The temperature may rise again after convalescence has begun. Such

a rise may be due to too liberal a diet, excitement, or constipation. It

may, on the other hand, be due to a relapse. Relapse occurs in about

10 to 15 per cent, of all cases. There is usually an apyrexial interval of

about five to ten days, but sometimes the temperature has never dropped

satisfactorily. The second attack is usually less severe and shorter than

the first. As many as five relapses may occur, though more than two

but rarely occur in this country.

498 PYREXIA [§864

TrealmerU, — The microbe of enteric fever, by virtue of its special
" proclivity," attacks Peyer's patches in the small intestine, which become
inflamed, swollen, and ulcerated. Consequently, there are three indica-
tions : (a) to prevent peritonitis, hsBmorrhage, or perforation by rest and
suitable diet; (b) to maintain the strength of the patient; and (c) to
neutralise the toxin of the microbe (by senun- therapy, see § 388).
Hygienic, — Absolute rest is of the highest importance, and when the diag-
nosis has become established the patient should not be allowed to turn
himself in bed. Grave responsibility rests upon the nurse in this respect,
for perforation may occur in changing the draw-sheet, owing to the patient
being allowed to raise himself for the purpose. It is a great mistake,
however, to keep the patient continually on the flat of his back, as it not
only tends to congestion of the bases of the lungs, but also conduces to
bedsores. He should be encouraged to lie on his side, and should be care-
fully turned every two hours on either side alternately. In contra-
distinction to the febrile diseases already described, typhoid fever patients
may be treated in a general ward, but great care must be taken to keep
all utensils and the thermometer apart and disinfected. The stools must
be burnt or immersed in izal directly they are passed, and 1 in 20 carbolic
must be added to the urine. All linen must be first steeped in an antiseptic
such as 1 in 20 carbolic, or lysol or izal, for several hours, and then boiled.
All pots, pans, mugs, etc., must be boiled after each occasion on which
they have been used. Diet is also of prime importance. Milk is the staple
article, and not less than 2 and not more than 3 pints a day should be
given, sufficiently diluted. It is advisable to add barley-water or lime-
water to prevent the formation of large curds. The addition of 3 grains
each of sodiimi bicarbonate, magnesium carbonate, and sodium chloride
to a cup of milk or sodium citrate in the proportion of 2 grains to the ounce
of milk, has a like result. If milk disagrees, give whey, egg albimien, or
butter-milk. Clear soup, chicken broth, and beef-tea may also be given.
No solids should be taken until at least one week after the temperature is
normal. The modem practice, however, of giving light and easily
digested solid food at an earlier date than this has something to recom-
mend it. Predigested foods are of great aid to promote assimilation,
especially if the tongue be heavily furred, and pepsin is said to have
quite a specific effect on the disease, though it probably acts in that way.
It may be given thus : Essence of pepsin, m^xxx. ; dilute nitro-hydro-
chloric acid, \]\ v. ; glycerine, ad 5i. The bowels must be regulated by
enemata on alternate days, if required.

Hydrotherapy. — Judging from the good results which this line of treat-
ment has given on the Continent and in America, its use is worthy of more
trial than it has hitherto received in England. It is applied in three ways :
(i.) By cold or tepid sponging ; (ii.) by the ice-pack ; and (iii.) by the bath,
which is used as a routine when the temperature is over 102*2^ F. At the
Johns Hopkins Hospital it is usual to give a bath at 70° F, every third
hour, if the temperature is above 102-5° F. The patient remains in the

§866] ENTERIC OR TYPHOID FEVER 499

bath for about twenty miautes, during which he is rubbed with the hand
or a suitable rubber, and is then taken out, wrapped in a dry sheet, and
covered by a blanket.

Medicinal, — Internal antiseptic remedies are largely used. Such are
perchloride of mercury, carbolic acid, creosote, izal, lysol, /5-naphthol.
These are not of much value, and treatment by drugs is chiefly sympto-
matic. If profuse, the diarrhcea must be checked by enemata of starch
and opium (oSs. of tinct. opii to giii. of mucilage of starch) ; or liq. mor-
phinsB, m^xx., with dilute sulphuric acid, IT^^x., eveiy three or four hours.
If this fail, give acetate of lead, bismuth carbonate, or bismuth salicylate.
If perforation occurs, laparotomy and suture of the bowel should be per-
formed immediately. For local peritonitis apply heat to the abdomen,
give opium in large and frequent doses, iced milk, and very small doses
of brandy or champagne. If the abdomen is tympanitic, reduce the amount
of milk, or give it more diluted, apply turpentine fomentations and give
turpentine internally. HcBmorrhage should be checked by the administra-
tion of opium, and absolute rest must be enjoined, and the amount of fluid
given should be cut down to the smallest possible quantity. To main-
tain the strength, stimulants are called for in certain cases, but they should
not be given as a matter of routine. The pulse is the best indication for
their administration ; they must be stopped if haemorrhage occur. Cinna-
mon oil has been strongly recommended by Dr. F. F. Caiger in 3 to 5 minim
doses every two hours throughout the illness. The oil must be pure, and
given in capsule.

Prophylactic Treatment is based upon a knowledge of the origin of the
disease and the mode of its introduction into the system — ^viz., by the
mouth (see § 390). The incidence of typhoid in a community is a fair
index of the purity of its water-supply. Preventive incubation by means
of sterile cultures of the typhoid bacillus on the lines originally recom-
mended by Sir Almroth Wright is now an established success, notably in
the army on foreign service, while as a curative measure Chantemesse in
Paris, by means of an anti-serum, claims to have treated 1,000 consecutive
cases of typhoid fever with a mortality of less than 5 per cent.

Febricnla is a term somewhat loosely applied to any condition which is chiefly
evidenced by a slight degree of fever and malaise. It was formerly classed as one
of the four Continued Fevers of Great Britain. Murchison^ showed that when it
assumed the form of a definite illness it was in reality a mild attack of typhoid fever ;
and that when death, which was a very rare event, did ensue, the characteristic lesions
of that disease were found in the intestines.

§ 365. Diphtheria (Synonym : Membranous Croup) is a contagious fever,
characterised by a membranous exudation on the fauces, due to the
Klebs-Loeffler bacillus (Chapter XX.). Symptoms, — The incubation period
is variable, but it is often about two to six days. (I) The onset is usually
gradual (extending over a day or two), but in some cases it is sudden.
The fever is often high, but in others it may not exceed 101° to 103°,
and it may even be quite normal (Bristowe) in very mild cases. The

^ " The Cbntinued Fevers of Great Britain," second edition. Marohison, 1873.

SOO PYREXIA tSM6

height of the temperature is no guide to the severity of the disease. The
temperature chart does not conform to a regular tyfe, but Fig. 98 represents
a common case. (2) Sore throat is present from the beginning, and fre-
quently dysphagia. On one or both of the tonsils there is a characteristic
patch of creamy white, wash-leather- like membrane situated on an
obviously congested surface. If forcibly removed, this leaves bleeding
pointo. As the patches extend they nin together, and may spread on to
the soft palate and uvula. Their occurrence on the soft palate or the
uvula is a diagnostic feature of great value from quinsy. The patient
complains that the neck feels very stifi, and the glands at the angle of the
jaw are nmUen. Thb glandular enlargement dates from the recognition

... _jls,»t.». An ordiiuiry c»aB ol taucltti diphOieria without luiiihcatiou

ol luyni- The p«Ule wu itUI uuntbctlc one moatb Ut«r. Not fallowed by pualyaii.
The diflsrent eveota ue iadlc&ted on the chut, for which the author la indebted to Dr. F. F.

of the attack, or even before, and is of importance in the diagnosis. The
membrane spreads to the larynx and bronchi in certain cases, and it may
also spread upwards to the nose (especially in children). An ichorous
discharge from the nostrils in a child lying prostrate and fretful in bed is
very characteristic of diphtheria. It may, in rare cases, involve, or start
upon the conjunctiva, genitals, or on the skin at the angles of the mucous
orifices. (3) Albuminuria is present in nearly hall the cases (Caiger) before
the end of the first week. There may be hyaline casts in the urine which
is sometimes suppressed towards the end in fatal cases. (4) Prostration
and ancemia are very marked, but the mind usually remains clear to the
end, even in lethal attacks. In the asthenic type of the disease lassitude

§ 866 ] DIPHTHERIA 501

and prostration are extreme. Eruptions on the skin are occasionally
met with, the commonest being an erythema, or purpuric spots in fatal
cases.

The Diagnosis of diphtheria may be made by finding the Elebs-Loeffler
bacillus in swabbings taken from the seat of the disease. The diagnosis
of the sore throat caused by tonsillitis, scarlatina, and diphtheria presents
certain difficulties, and is given in the tabular form (§ 111). Follicular
tonsillitis is distinguished by the absence of the definite wash-leather-like
patches on the fauces, nose, or larynx, and usually the presence of higher
fever. There may also be a history of previous attacks, though an in-
ference based on this may be very misleading. Albuminuria, too, is
much less common. Scarlatina is distinguished by its abrupt onset, its
higher fever, its rash, strawberry tongue, and generally the absence of
membrane from the throat. Simple ^^ croup ^^ (catarrhal laryngitis) is
distinguished by the absence of patches in the throat, but this is often the
case in true diphtheria. Membranous croup is always diphtheritic.
Vincent^ s Angina is distinguished by the bacteriological examination (§ 110).

Etiology. — The disease occurs chiefly in the young, and especially under
ten years of age. It is also predisposed to by scarlet fever, measles,
whooping cough, and other acute afEections. There seems to be a more
marked tendency in certain families to contract it than is the case with
other infectious maladies. The disease spreads from person to person ;
it may be conveyed by instruments, infected handkerchiefs, cups, spoons,
slate pencils, and kissing, etc., and it hangs aboiU a house or district with
remarkable tenacity. Nurses and medical men frequently contract the
disease by the patient coughing into their faces. It may also be conveyed
by milk ; but there is no evidence that it is conveyed by water. Some hold
that the disease is predisposed to by bad air from drains, and undoubtedly
a form of sore throat may be thus developed. It is probable, however,
that these conditions only favour the development of the diphtheria
bacillus. Human beings may contract the disease from cats, and epi-
demics have been produced in this way.

Prognosis, — The case-mortality varied widely in different epidemics, but
it used to be an average from 25 to 50 per cent. Since the introduction
of the serum treatment the mortality has fallen to less than 10 per cent,
in hospital cases (Caiger). The malady is often fatal by the spread of the
membrane to the larynx during the first week of the disease in little
children. After the first week death may take place by toxaemia, cardiac
failure, or other complications. Pharyngeal cases are, in adults, usually
mild, and recover in a week or so, but severe cases last two or three weeks.
Great care is required even in the mildest oases, lest the membrane should
spread, and in the more severe on account of the complications {q,v,),
particularly cardiac failure. The clinical varieties according to Caiger
(loc. cit.)y are (1) mild/audal cases, mostly met with in adults ; (2) severe
faudal cases, with a tendency to extension, chiefly met with in young
children ; (3) " croup " or larythgeal diphtheria, where the air passages

502 PYREXIA [§366

are alone afEected ; (4) nasal diphtheria, where the nasal passages only
are afEected ; (5) diphtheria of other parts — cheeks, gums, tongue, lips,
c«njunctiv8B, genitals, wounds, etc. — conditions generally associated with
faucial or laryngeal diphtheria. UrUoward Symptoms. — The prognosis is
unfavourable when the temperature is low in spite of severe local lesions,
especially if attended with suppression of urine ; when epistaxis or any form
of hcBmorrhage occurs, particularly purpuric spots in the skin, such cases
being invariably fatal. Speaking generally, the prognosis will be influenced
by the extent, thickness, and persistence of the exudation, the danger
being accentuated in proportion to the youth of the patient. Sapid
extension of the membrane is also a grave sign, especially when it extends
down the larynx, leading to croupy cough, dyspnoea, and cyanosis ; and
death takes place in such cases from asphyxia, unless they are promptly
relieved (see below), whether as the result of antitoxin or by the per-
formance of tracheotomy or intubation. The chief danger in the second
week is cardiac dilatation and failure, and the pulse and heart should be
closely watched at this time. Of the compHcations, certainly the com-
monest is paralysis, due to peripheral nerve degeneration. It attacks in
some degree from 15 to 20 per cent, of the cases (Caiger), and comes on
usually about the third or fourth week, sometimes later. The character-
istics of diphtheritic para]ys:s are : (i.) It starts usually in the palate, and
therefore nasal voice or dysphagia is the earliest symptom, and fluids
taken are returned through the nose. The paralysis is progressive, and
tends to involve many of the muscles of the body. Next in order we may
get loss of accommodation, squint, loss of patella reflexes. Among the
most serious paralyses are those of the diaphragm and intercostals.
(ii.) Motion and sensation are simultaneously aflected, though often the
sensory symptoms are the first to be observed. The attitude assumed in
marked cases is very characteristic — the little patient in protracted cases,
if getting up, shambles into the room with drooping shoulders and head
bent forward from weakness of the trunk and neck muscles, (iii.) The
heart is frequently affected, which sometimes leads to sudden death if the
patient be not kept absolutely still. The sounds are weak, and the
rhythm rapid and irregular, often of the "galloping" type. Vomiting
usually accompanies such cardiac signs, (iv.) In general terms there is
a tendency to complete recovery in a few weeks, though sometimes death
occurs — apparently from involvement of the vagus. (2) Broncho-pneu-
monia, so frequent formerly, only attacks about 4 per cent, under modem
methods of treatment, but cardiac dilatation, probably due to myocarditis,
is a frequent occurrence. (3) Nephritis and dropsy during convalescence
are very infrequent, and permanent lesions of the kidney are rare. Otitis
media is not unconmion.

Treatment. — The indications are (a) to neutralise the toxin in the
blood ; (6) to inhibit the local process ; and (c) to strengthen the con-
stitution to resist the disease. (1) Thanks to the recent advances in
science, we now have a powerful antitoxin for the control of the disease,

§ 866 ] DIPHTHERIA^INFLUENZA 503

and if given early it is capable of completely neutralising the toxin and
arresting the disease. It is a good general rule to give it in all cases,
though there are three possible exceptions^ — ^viz., (i.) very slight cases,
when under constant medical observation ; (ii.) cases seen too late in the
course of the disease, when membrane is obviously separating (the anti-
toxin should be given at the earliest possible moment ; doses and methods
are given, §§ 386 et seq.), (2) For the local treatment, nitrate of silver,
hydrochloric acid, and other caustics have been much used, but are now
condemned as useless and harmful ; and papain, with borax, had a reputa-
tion which no longer exists. Disinfectants are certainly useful, applied
by syringing, or spraying, or swabbing every hour or so, with 1 in 10,000
corrosive sublimate, or carbolic acid (J per cent.), but the best resiJts have
been obtained with chlorine (F. 18), formalin J per cent., or sulphurous
acid, used by syringing or spraying. Steam inhalations every half-hour
and hot applications to the neck give much relief. When the nose is
afEected it must be syringed with the same, though weaker, disinfectant
solutions. When the larynx is involved the question of tracheotomy or
intubation has to be considered. Statistics used to be very unfavourable,
the mortality being 70 or 80 per cent. But in the present day from 70 to
80 per cent, of the cases operated on recover, and either tracheotomy or
intubation should be performed promptly whenever the breathing is
difficult owing to laryngeal obstruction, provided antitoxin has not been
given sufficiently long before to lead one to expect early separation of the
membrane. The results are more satisfactory when it is done early, and
all laryngeal cases should be closely watched for the epigastric retraction
during inspiration which indicates severe inspiratory obstruction. It is
then essential to keep the patient in a steam-tent. (3) The constitutional
treatment consists of stimulating and supporting measures. In asthenic
cases perchloride of iron and potassium chlorate are generally given, with
wine, beef-tea, and abundant nutriment. In the inflammatory stage give
diuretics and potassiimi chlorate, with salines and laxatives. In all cases
the patient should be kept quite still in the recumbent position for fear
of the heart failure, which is apt to occur, especially about the tenth to the
twenty-first day in severe cases.

§ 866. Influenza is an epidemic fever attended by considerable prostra-
tion, and usually by catarrh, and a tendency to the development of local
inflammations. It has been known for at least five centuries, and has
occurred at various times in great epidemics, separated sometimes by
many years' interval.

Symptoms. — (1) After an incubation period of one to six days the
patient's temperature goes up in the course of a few hours to 102° and
104° F. The onset is frequently attended by severe headache and shiver-
ing. The fever generally ends in one to five days with profuse perspira-
tion, and is attended by the pains in the limbs which form such a charac-
teristic feature of influenza. (2) "Catarrh" usually accompanies the

* See also Wwhbourn, Lancet, October 14, 1890, p. 1019,

504 PYREXIA [§

fever — i.e., there are redness and watering of the eyes, running at the nose,
sore throat, sneezing, and tightness of the chest. (3) Malaise and prostra-
tion out of proportion to the amount of pyrexia occur. There is usually
a loaded, pasty tongue. (4) Some cases have only the three symptoms
just mentioned, but there is a great tendency to local complications. The
type of the disease therefore varies according to the physiological system
mainly involved, (i.) The respiratory tract is very frequently attacked,
and in that case bronchitis and pneumonia complicate the disease, (ii.) The
circulatory system may be affected by endarteritis, and occasionally, but not
often, by other gross lesions. The neuro-vascular apparatus is, however,
specially prone to suffer, causing tachycardia and bradycardia, palpita-
tion, flushings, faintings, perspiration, dyspnoea, and the like, (iii.) In-
volvement of the alitnentary tract may be evidenced by gastro-enteritis,
diarrhoea, vomiting, jaundice, etc. (iv.) Eruptions on the skin may occur,
especially urticaria, erythema, or rose-spots like measles, (v.) The
nervous system, especially in the aged, is affected for long after the disease,
and neurasthenia is particularly apt to supervene. Peripheral neuritis is
frequent, and many cases of disseminated sclerosis are attributed to this
disease. Depression, prolonged mental dulness, and other symptoms are
met with.

The Diagnosis is not difficult in typical cases, especially when the
disease is prevalent. The short duration of the initial symptoms and the
usual absence of rash are sufficiently characteristic. The severe pains in
the limbs are very t3rpical.

The Etiology is still obscure, though a specific microbe has been isolated,
which occurs chiefly in the secretion of the respiratory tract. It is un-
certain whether this is the only organism capable of causing influenza.
It is certainly epidemic. One attack confers no immunity from a second.
As regards predisposing causes, age has no influence, nor have seasons of
the year, nor sanitary conditions. Old and young, rich and poor, all are
attacked alike.

Prognosis, — The case-mortality is about 1 per cent, among the old and
young together. In middle-aged and elderly people the respiratory type
is very apt to end fatally with pneumonia, and undoubtedly many cases
presumed to be primary pneumonia are really secondary to influenza.
It is fatal only through its complications. The disease itself is usually
trivial, and the patient soon recovers. Relapses are not infrequent. The
complications consist of those mentioned above imder types of the disease.
The sequdcB are prolonged weakness, peripheral neuritis (sometimes
attended by tremors), otitis, orchitis, meningitis, and mental de-
rangement.

Treatment. — ^During the attack the patient should be kept in bed in
view of the complications and sequelae. Sodium salicylate, antipyrin, and
antifebrin will reduce the fever, and relieve the pains in the limbs, and
ammoniated tincture of quinine is a justly popular remedy. Cinnamon
oil has been advocated. For the rapid heart liquor arsenical is is recom-

{ S67 ] RHEUMATIC FEVER 505

mended ( l\iv. t.d.s.).^ It is well to keep elderly people indoors (or away
from infection) during the prevalence of the disease, as they run greater
risks from its effects.

§ 867. Bhenmatic Fever, Pneumonia, and other Inflammatory Disorders,
which usually present well-marked local maniJtostations. — The three fevers
just described are those most commonly met with in England, in which
the pyrexia may run a continued course, and which have no eruption
during the first four days. But it must not be forgotten that certain
inflammatory disorders may give rise to pyrexia of a continuous type,
and that the usual local signs of these disorders may be absent, at the time
when the patient is first seen. It will be well, therefore, to mention those
which might be mistaken for an acute specific fever.

(a) Obscure (so-called) Local^ Inflammatory Diseases are mostly
met with as complications secondary to fevers. They can usuaUy be
detected by a thorough examination of all the organs in the body (§ 349).
Nevertheless, certain cases of (1) pericarditis or malignant endocarditis , or
(2) pneumonia or pleurisy, may be latent — i.e., the usual physical signs
may occasionally be wanting or overlooked. (3) Various affections in or
around the thro€U and nose ; (4) some ahdominal disorders, such as peri-
hepatitis, inflammation of the mesenteric glands or pancreas, deep-seated
abscesses (hepatic, subphrenic, perinephric, tubal), etc. ; (5) certain rare
cases of sarcoma and cardrwma ; or (6) inflammation of the m^nin^es,
tuberciJous or epidemic, may also give rise to an elevation of temperature
sometimes unattended by marked local symptoms ; (7) parasitic infections,
trichinosis, actinomycosis. Cabot finds that in obscure cases of long-con-
tinued fever the causes to be suspected are pulmonary or renal tubercu-
losis, enteric fever and deep-seated abdominal abscesses, and endocarditis
(compare § 384).

(h) Certain obscure General Inflammatory Disorders are attended
by pyrexia, which may similarly give rise to difficiJties in diagnosis.
(1) In rheumatic fever and acute gout the pyrexia is nearly always con-
tinuous. The joint lesions are the cardinal feature in these c£U3es ; but it
must not be forgotten that acute rheumatism may commence with inflam-
mation of the pericardium (the structure of which very much resembles
that of a joint), and that the joint lesions may not be apparent for several
days. (2) There are several conditions special to infancy and childhood
which are attended by continued pyrexia : (i.) InfafUUe paralysis (acute
anterior poliomyelitis) is attended at its outset by a considerable rise
in temperature, which may last for several days or weeks, and be accom-
panied by restlessness, peevishness, etc. ; (ii.) rickets from time to time may
have a slight degree of fever, accompanied by a generalised tenderness and
profuse perspiration ; and, as just mentioned, (iii.) meningitis, tuberculous
or epidemic. (3) A nervous or hysterical pyrexia has been described, and

^ Samson, *' Effects of Influenza on Heart and Cirotilation,** Lancet, October 21,
1899. p. 1076.

2 The word " local " is here used in a qualified sense. Many of these diseases with
local manifestations are now known to be due to a general infection.

506 P YREXIA [ §§ 368. 899

I have seen the temperature go up in an erratic manner, at odd times, in
nervous subjects. But while admitting that the nervous system plays a
very important part in the production of fever (as witness the rigors and
pyrexia which follow catheterisation), it is difficult to believe that there
is not a compound cause in operation in such cases. Only a thorough
post-mortem and bacteriological examination would enable us to be certain
that none of the many obscure foci of inflammation above mentioned were
present.

§ 868. Whooping Oongh (Pertussis) is an acute speoifio infectious malady, char-
acterised by paroxysmal attacks of coughing, followed by a long noisy inspiration (the
whoop). According to Bordet and Gengou the causal organism is a short bacillus
which is present in the respiratory mucus. The period of incubation is from three to
fourteen days (usually nearer the latter). (1) The onset is marked by a preliminary
catarrh, or running from the nose and sometimes the eyes, attended not infrequently
by paroxysmal dyspnoea and drowsiness. This premonitoiy stage lasts from tJiree or
four days to a week or more, and may be overlooked. (2) Paroxysms of coughing
then set in. Each paroxysm consists of a series of short sharp coughs, followed by
a laud ins^ratory ** crow," through the narrow chink of the half -closed glottis, and it
is often followed by vomiting — a diagnostic feature of value when we have to depend
on the mother's account of the case. As the result of the coughing, large quantities
of stringy mucus, often blood-stained, are expectorated. After some days the face
remains somewhat swollen as the result of the straining cough, and subconjunctival
hsBmorrhages or epistaxis may also occur. There are no physical signs characteristic
of the malady, unless, as some maintain, enlarged bronchial glands can be detected
by percussion over the root of the lung. Bronchitic sounds are generally present
in greater or less degree. (3) The constitutional symptoms vary considerably in
severity. In many cases they are absent, the temperature being hardly elevated,
and the child being apparently quite well between the attacks oC coughing. In
typical cases, however, during the catarrhal stage, there is slight pyrexia. The
Diagnosis is not difficult, since the paroxysms of coughing are veiy characteristic,
though a typical ** whoop '* may never be developed. In the abscnco of the whoop,
lymphocytosis aids diagnosis.

Prognosis. — All the symptoms increase for the first ten days, then remain stationary
for a few days, and decline during the ensuing two or three weeks. It is usually one
of the trivial ailments of childhood. It is severe only in very young children, in the
weakly and rachitic, or by reason of its complications, of which there are three chief
ones — viz., bronchitis, broncho-pneumonia, and convulsions, the two latter being
very fatal. Ulceration of the frenum of the tongue is common, due to the forced
protrusion against the teeth in the act of coughing.

Treatment. — In view of the fact, which does not seem to be sufficiently known,
that children living near gas-works and bleacbing-works do not get the disease, it
would be worth while to try inhalations of coal tar. Belladonna is, in my experience,
the most useful amongst the drugs, though nothing seems to cut short ^e malady.
It should bo given in large doses ; children will stand 10 to 20 minims of ^e tincture
if the dose be increased gradually. Antipyrin, hydrocyanic acid, carbonato of
ammonia, ipecacuanha wine, conium, and the bromides have also been recommended.
How long a child remains infectious is an important practical question. Infection
does not necessarily last as long as the characteristic cough is present, but when, as
in some cases, it is hard to say whether the attacks are typical or not, it is best to take
three to four weeks from the commencement of ^e disease as the duration of the
infection.

§ 869. Mnmpf (Acute Epidemic Pazotitii) is an acute febrile infectious disorder,
characterised by inflammatory swelling of one or both parotid glands. The period of
incubation is from one to three weeks, and in exceptional cases three or four days longer.

The Symptoms are moderate fever (102^ F.), subsiding in the course of three or
four days to a week, stiffness of the jaw, and difficulty of swallowing, due to swelling
and inflammation of the parotid gland. One side is first affected, and is succeeded by

§S 869a, 870] GLANDULAR FEVER— PLAQUE 607

the other in about twenty-four hours, or a day or two later. Sometimes the sub-
maxillary and sublingual glands are also involved. The glands may swell so
as to prevent the patient opening his mouth more than a quarter of an inch,
and there is usually marked salivation. They are acutely tender, and disfigure the
patient very much, but the malady is essentially a trivial one. The Diagnosis of
parotitis is very simple, the swelling of the glands being unlike anything else. The
only difficulty is between mumps and simple parotitis, such as occurs in enteric and
typhus fevers, in abdominal diseases, after laparotomy, or in connection with oral
sepsis ; but mumps is always bilateral, and never suppurates. Etiology. — It is almost
entirely confined to children and young persons between the ages of five and twenty.
It is rare in the very young and very old, but is often epidemic and runs through a
schooL A patient remains infectious as long as there is any definite swelling of the
glands. Prognosis, — Death from the disease is unknown, and the patient is generally
quite well in ten or twelve days at the outside. The chief danger is the swelling of
the tonsils and submaxillary glands. In delicate subjects the swelling is slow to
disappear. The comflications consist of (1) enlargement of the tonsils, and (2) orchitis
and ovaritis. In these circumstances a very curious phenomenon occurs, for as the
testis swells the parotitis subsides. It is the best instance of the phenomenon called
*' metastasis." The mammary glands may also become swollen and tender. In
some epidemics the swelling of the mamma or testicle precedes or accompanies that of
the parotid, and epidemics have been known in which the former were involved
without any parotitis. Occasionally these metastatic inflammations are attended
with severe constitutional disturbance, and the affected glands may become perma-
nently atrophied. Treatment. — The patient should be kept in one room. Warm
anodjrne fomentations may be applied, and if tension is present, leeches give relief.
Diaphoretics and purgatives are useful, and nutrient enemata may be required.

§ 869a. Glandular Fever is an infectious fever occurring in epidemics, in children
under fourteen, of cause unknown. After an incubation period of five to seven days the
symptoms are : (i.) Sudden onset of fever, 101° to 103® F., with vomiting ; (ii.) transient
sore throat ; (iii.) painful enlargement of the lymphatic glands appears on the second
or third day, without redness or cedema of the skin. First the cervical glands are
involved, then the axillary, inguinal and mesenteric, (iv.) Abdominal tenderness, with
some enlargement of the liver and spleen. The glands begin to decrease in about five
days, without suppuration, and the fever may remain till they subside in two to three
weeks* time. Comj)lications are otitis media, retropharyngeal abscess, nephritis,
and ansemia. Treatment is symptomatic.

The remaining fevers in this group are Plagttb, Ybllow Fevbr, Malta Fever,
which are met wi^ abroad ; Relapsing Fever, met tvith only in times of famine ; and
Efidsmio Cerebro-spinal Meningitis, which until recent years Jias for a long time
been rare in this country. In Hay Fever, Dysentery, and Cholera, there is some
disturbance of the temperature,

§ 870. Plague (Bubonic Plague, Typhus Bubonious, Oriental Plague, the Black
Dea^) may be defined as a highly infectious and fatal fever, characterised by inflam-
matory, glandular, and periglandular swellings, hsemorrhages beneath the skin and
from the mucous membranes. The last great epidemic in London was in 1666. Its
chief endemic centres in the present day are Northern India, China, Mongolia, and
Uganda. Since 1894 there has been a pandemic over most of the civilised world,
and our present knowledge of the disease is therefore greatly increased.

Symptoms, — (1) The incubation period is from two to eight days. (2) There is
often a prodromal stage, with depression and pains, but usually the onset is sudden,
with shivering, and fever rising to 103® or even 107® F. Mental aberration is not
uncommon. The prostration is very marked, and may be accompanied by vertigo,
staggering gait, and lethargy, soon passing into the typhoid state. The spleen and
liver are usually enlarged. In some cases the speech is halting and staccato, the
expression vacant, and the eyes congested. (3) Buboes (inflamed glands) appear in
one to five days, usually within twenty-four hours. They may be single, or a group
may be affected in one place, femoral or axillary ; sometimes they appear in several
parts of the body at once. They may be painless or very paiiiful, and they may

508 PYREXIA [ § S71

suppurate about the seyenth day. (4) PetochisB and subcutaneous hsemorrhages are
not uncommon. A distinctive rash is rare, but when present it resembles typhus.
There are six principal varieiita, which prevail in different epidemics : (L) The hubonic
variety is the commonest, glandular swellings occurring in quite 70 per cent, of all
the oases ; (ii.) the aepttccemic type is very fatal : the glands enlarge slightly, but thoy
do not suppurate ; (iii.) an o^orftve form, in which there are buboes without much fever,
subsiding in fourteen days ; (iv.) a fulminant form, with high fever, little glandular
enlargement, vomiting of blood, and death within a few hours ; (v.) a pneumonic form,
which may be mistaken for bronchitis or lobular pneumonia, attended by intonso
prostration, no glandular enlargement, and doath usually on the third to the iiftK
day, the pulse-respiration ratio being not so much altered as in true pneumonia ; and
(vi.) an amhvlani or mild form, with chronic glandular enlargement, great anemia,
and weakness. The Diagnosis is not difficult if sudden onset, marked prostration,
mental state, and bubonic swellings be present. The bubo should be punctured before
suppuration occurs, when the characteristic bacillus will be found. It is also found
in the sputum in the pneumonic form, which variety, indeed, can only be diagnosed
by the presence of the bacillus. The sputum in appearance resembles that met with
in heart disease. Plague closely resembles typhus in a concentrated form, but a rash
is rare in the former ; and the microbe of plague is distinctive.^ Inquiry should be
made as to the presence of dead rats in the neighbourhood.

Etiology. — Plague is due to the bacillus pestis, discovered first by Kitasato, and
later by Yersin. It was observed that outbreaks of plague wore often preceded by a
large mortality among rats and other vermin, and it is now known that the bubonic
form of the disease is carried by rats. The fleas infesting rats convey the infection
to man. Filth and overorowdiing predispose to plague. The pneumonic form is
directly conveyed from man to man by the sputum. Age and sex have little influence.
Prognosis, — ^The case-mortality in the early periods of epidemics is generally 60 per
cent. In well cared for white patients the mortality varies from 20 to 40 per cent. In
the usual course of bubonic plague death occurs before the sixth day ; or, if the patient
is to recover, convalescence starts between the sixth and tenth day. The pneumonio
variety is so fatal that of 43,000 cases in Manchuria only three recovered. Pro-
longed suppuration of the glands may delay convalescence considerably. The course
of the disease is very difficult to forecast. Hsemorrhages usually herald death. Tho
sequdcB include boils, pneumonia, dropsy, partial paralysis, and mental disorder.

TrecUment, — ^Extermination of rats is part of the prophylactic treatment. Tho
hygienic and therapeutic treatment are as in typhus (see also §§ 386 et seq.). The
injection of carbolic acid into the glands has been practised with some success, and
large doses by the mouth are also recommended. Some advia3 excision of the glands.
Immunisation is now obtained by inoculation of serum if commenced early in the course
of the disease. Inoculation is also used as a preventive treatment in affected districts.
§ 871. IFndnlant Fever (Synonyms : Malta Fever, Mediterranean Fever, Gibraltar
Fever) is a disease of subtropical and tropical climates with endemic areas, par-
ticularly in those countries wUch border on the Mediterranean, and in the Punjaub.
It is caused by a specific organism which is conveyed to man by the milk of infected
goats. The goats do not show any sign of ill-health.

Symptoms. — The incubation period is fourteen days ; the prodromata include
malaise, muscular pains, and dyspepsia. A doctor may not be consulted for the
first few days, but then the increasing headache, fever, and muscular pains cause tho
patient to seek advice. The temperature keeps high (102° to 104° F.) for about
fourteen days, and may then drop for one or two days, only to rise again. After
several relapses and intermissions the temperature becomes undulant in character,
with a marked rise at night. The general health of the patient suffers in many ways,
the chief symptoms being gastro-intestinal. There are muscular and joint pains,
which may be accompanied by considerable swelling, sore throat, ansemia, enlarged
painful spleen, and bronchitis. There are three varieties of the disease. Tho malignant
is of acute onset, and runs a rapid course to a fatal termination, preceded by the

1 The Code of regulations for searchers of the plague, issued by the Royal College
of Physicians in 1665, mentioned a rash as a means of recognising tho disease, but
probably typhus was confused with plague.

§872] YELLOW FEVES 609

typhoid state and hyperpyrexia. The iniermiUetU varioty is of very slow onset, and
runs a long course, with elevation of the temperature each evening. The patient does
not as a rule make any complaint of specific symptoms until his general health begins
to be affected. The ambulatory type includes the not infrequent oases in which the
micrococcus melitensis is found in the blood of persons who are in no respect ill.

Etiology. — ^The organism responsible is the micrococcus melitensis. It affects goats,
and their milk is thon infectious.

The diagnosis is arrived at from the clinical signs and the agglutinin reaction of the
blood, which should prove positive in a dilution of 1 in 60 in thirty minutes before
being accepted as final.

Prognosis, — In the common type the mortality is about 3 per cent. Complications
are orchitis, diarrhoea, pneumonia, cardiac failure, and hyperpyrexia, the latter being
the usual cause of death. The disease may last 300 days ; the average is 90 days.

TreatmerU. — Care must be taken to support the heart, and the use of digitalis is
often indicated. Pains in the joints may yield to hot fomentations, but morphia may
be necessary. The patient should be moved to a cooler climate if the disease begins
in summer. Sir A. Wright has prepared a vaccine. Prophylactic treatment consists
in avoiding goats' milk.

§ 872. Yellow Fever is an acute specific fever peculiar to hot climates and seaport
towns, accompanied by jaimdice, black-vomit, and the typhoid state.

Symptoms, — (1) The incubation period is short, probably from four to five days.
One attack usually renders the patient immime for life. Yellow fever has a sudden
onset, the temperature rising on ^e first day to 101°, 105** ¥,, or even higher, and
it remains high for three or four days. The pulse does not rise in proportion, and
later it becomes distinctly slow. The temperature then falls to normal, or at least
lomits greatly ; and though it may rise again, the second fever is not so high. (2) Albu-
minuria is a constant sign, occurring usually the day after the onset. Granular casts
cro frequent. The diazo reaction occurs sometimes. (3) In most cases jaundice and
vomiting appear about the third day, but in mild cases those may be absent, as may
also the yellowness which has given the fever its name. The epigastrium is h3rper-
sensitive. In severe cases the jaundice is intense, with petechise, the vomit is mixed
with bile, and in the later sta^ with blood, forming the '* black- vomit." Hsemor-
rhages may also occur from the gums, stomach, nose, and bo web. There is no splenic
enlargement. There is leucopenia, with moderate increase of the percentage of
mononuclears. The liver has a degree of fatty degeneration, and the bloodvessels
supplying the stomach and intestines are in a state of degeneration, and readily
rupture.

Diagnosis, — Yellow fever has to be diagnosed from many tropical fevers. Important
points are albuminuria, slow pulse, epigastric sensitiveness, and slight jaimdice. In
malaria the spleen is enlarged, and the parasite is found in the blood. In Blachvater
fever there is a bilious vomit, which may cause it to be diagnosed as yeUow fever, but
it is accompanied by haemoglobinuria, and no blood corpuscles are found in the urine ;
whereas in yellow fever, if the urine is red, it will be found that the condition is due to
the presence of blood corpuscles. Acute Yellow Atrophy of the liver has a more gradual
onset, and is more common in women. Other forms of jaundice have not the leuco-
cjrte alterations met with in yellow fever.

Etiology, — Yellow fever is peculiar to the West Indies, certain parts of America,
the Brazilian ports, and the west coast of Africa. It is found only in seaport towns.
It rapidly spreads, especially in those parts which are crowded and dirty. It is
always worse in the summer months, as a high temperature is necessary for the exist-
ence of the mosquito. A slight frost will destroy it, as at Memphis in 1879. It has
been proved that it is transmitted, like malaria, by a mosquito (Stegomyia calopus),
but f^e specific germ has not yet been demonstrated. It is ultira-microscopio, and
passes through a Pasteur filter. It is erroneous to state that negroes do not contract
the disease. The disease does not spread so rapidly amongst them as among Euro-
peans, probably because many of them have been rendered immime by a previous
attack.

Prognosis. — The case-mortality varies in different epidemics from 6 to 94 per cent.,
and has not improved of recent years. Sometimes the patient recovers uninterruptedly

610 PYREXIA [ § 878

after tho fovor falls on the fourth day ; in such oases the skin is moist, there is little
albumen or vomiting, and little or no yellowness. On the other hand, death may
occur with " typhoid state " a few hours after the onset of disease, or from collapse
after the fever remits. The prognosis is always grave when the jaundice is intense,
the vomiting frequent, and hsBmorrhages occur from the stomach or elsewhere.

Treatment. — Prophylactic treatment consists in the destruction of mosquitoes, and
protection from their bites. Patients with yoUow fovor must be screened from mos-
quitoes, lest these convey disease to healthy persons. One of the firet indications is
to diminish the work of tho portal system by attention to the diet. Vichy water or
mutton broth (2 litres of fluid daily) should be given ; no solid food must be taken.
Rectal feeding may be necessary. Purgative waters should be given. Symptomatic
treatment consists of ice and astringents for the hsamorrhage, cold sponging and
codein for the headache, and strychnine for the heart. No antipyretics should be
taken. It is important to induce free elimination by the skin and kidnejrs. As soon
as the urine diminishes, saline injections should be given subcutaneously, 1,000 c.c.
daily, in two or three injections. When the temperature has been normal for two
days solid food may be taken if the urine is secreting and the gastric irritation has
subsided. No work must be undertaken imtU the pulse resumes its normal rate.

§ 878. Epidemic Oerebro-Spinal Meningitis (Synonym : Spotted Fever) is charac-
terised by (1) fever, sometimes very irregular at the onset, becoming normal for a
day or two, then rising again. It may be remittent, but not often. It is rarely over
102° to 104° F., but may be considerably raised towards the end. The pulse frequency
is not always proportional to the degree of fever. (2) Symptoms of irritative intra-
cranial inflammation, such as very severe headache of sudden onset, delirium, vomiting
and muscular spasm. Compression symptoms may supervene later. The so-called
" Kemig's sign " — i.e., when the thigh is flexed at a right angle to the abdomen, the
leg cannot be extended because of spasm of the flexors of the thigh — ^is usually present.

(3) There is always retraction of the head, and sometimes opisthotonos may be present,
owing to the rigidity of the muscles of the back. HypersBsthesia, especially along the
spine, and severe pain in the back, may be so great that all movement is intolerable.

(4) A prominent feature is the presence of some skin affection, very often occurring
symmetrically. Herpes labialis or zoster is frequent. On the second day or later a
rash of purpuric spots sometimes appears, and may cover the body. Its frequency
varies considerably in different epidemics, for in some it has been a rare symptom.
Urticaria and er3rthema may occur. (5) Leucocytosis appears early.

Diagnosis. — ^This disease has to be diagnosed from tuberculous meningiiis, which
has an insidious onsot, and no eruption. From other forms of meningitis the best
method of diagnosis in doubtful cases is by lumbar puncture, when the fluid will be
found to be turbid, and to contain the specific diplococcus. When an epidemic is
present, there is little difficulty in the diagnosis. Care should be taken to exclude
anterior poliomyelitis with acute onset, in which a stage of cerebral irritation lasting
even as long as seven to ten days is not uncommon.

Etiology. — The disease attacks persons under twenty usually, and some epidemics
have occurred chiefly among young infants, and males more than females. It never
occurs in summer, and is most frequent in winter and spring. It does not appoar to
be contagious, although it usually occurs in epidemic form. Epidemics are localised
and not widespread. It is due to a specific micro-organism, the diplococcus intra-
coUularis meningitidis, described by Weichselbaum, which is non -Gram-staining, and
may be grown on agar or ascitic fluid. It is foimd in half the cases in the naso-
pharynx, and is apparently carried by healthy subjects.

Prognosis. — ^The disease has a case-mortality of 30 to 70 per cent. Tne usual course
of the malady is three weeks ; but there are four varieties based upon the duration
besides the common form above described : (i.) The foudroyant form, which kills the
patient in a few hours or days ; (ii.) tho typhoid form, which lasts for several weeks ;
(iii.) the form which recovers in a few days ; and (iv.) a chronic form, lasting for months.
The prospect of recovery is not good when tho disease attacks infants or old people.
Amongst the unfavourable signs are the occurrence of hyperpyrexia, convulsions,
irregular breathing, or an imduly prolonged period of illness. The more common
complications are inflammation of the joints, optic neuritis, and polyuria. A trace of

IS74] RELAPSING OR FAMINE FEVER 611

sugar may appear in the urine. Amongst the sequelsB may be mentioned deafness,
impairment of the vision, ohronio hydrocephalus, and transient paralysis of the limbs,
or aphasia.

Treatment. — Hitherto the treatment has been mainly symptomatic, for the relief
of the pain and the fever. Repeated lumbar punctures have been recommended as
a curative measure, but apparently do little more than temporarily relieve the pressure
symptoms. Recently Mexner's serum has given great promise of success. After
withdrawing 50 o.o. of cerebro -spinal fluid, 30 c.c. of the serum are injected on several
successive days.

§ 874. Relapsing or Famine Fever [Synonyms : Recurrent or Relapsing Typhus,
Spirillum Fever (Vandyke Garter)] is a contagious fever met with in times of famine,
ending abruptly on the fifth, sixth, or seventh day, and followed after an interval of
one week without fever by a relapse similar to, but shorter than, the first attack. The
incubation period varies from five to nine or more days.

Symptoms. — (1) The fever has a sudden onset, and rises rapidly. It sometimes
roaches 108° F., a range which in other diseases is not consistent with life. After
remaining elevated for six or seven days, the temperature returns to normal as rapidly
as it rose. The fall is preceded and attended by profuse perspiration or diarrhoea,
or both. This is followed by an interval of about a week, during which the patient
feels exhausted, and the pulse and temperature are subnormal. At the end of this
week a relapse occurs which is similar to the first attack, but shorter, lasting three or
four days. In rare cases there is a second and even a third relapse. (2) Abdominal
pain and tenderness, and great enlargement of the spleen and liver, are present in
almost all cases. Jaundice is also very common. Epistaxis is common, and sometimes
there is vomiting of blood. Delirium is very rare, but if present is of the noisy kind,
and occurs at the crisis. Convalescence is slow. (3) The Spirillum is found in the
blood during the pyrexial period, but in the intervals it is only present in the spleen.

Diagnoeis. — ^The diagnosis is not difficult, on account of the circumstances under
which the disease occurs, and the course of the temperature. Enteric fever and emaU-
pox cause rash ; rheumatic fever is associated with joint losions. Yellow fever, which
it most resembles, produces jaundice, and a diagnosis is only made by the course of
the fever and the presence of the Spirillum in the blood in relapsing fever.

Etiology. — ^Relapsing fever is due to a specific spirillum, the spirochsete of Obermeier.
The disease arises under the conditions which attend a famine, and has been noticed
to accompany most epidemics of typhus, in which circumstances the epidemic
begins with relapsing fever and ends with typhus. The disease appcjirs in seasons
of unusual distress, as during strikes. It does not occur with ordinary desti-
tution, but in times of famine, when people eat unwholesome articles, such as grass,
roots, hay, etc. Overcrowding is not absolutely necessary for its production, in which
respect it differs from typhus. One attack does not confer immunity from a second. As
regards the Predisposing Causes, age has no influence, nor have seasons or occupation.

Prognosis. — ^Tho case-mortality is not nearly so great as that of typhus ; it rarely
exceeds 2*5 per cent. Age has not much influence, but dissipation and debility are
unfavourable. Death, which occurs generally at the height of the first attack, is
usually due to syncope, from haBmorrhage or from degeneration of the heart.
When occurring later, it may be due to complications. Untoward symptoms
are : More than one relapse, heemorrhage, suppression of urine, the typhoid state,
cerebral symptoms, or indications of a weak heart. A rapid pulse, a high temperature,
and even jaundice, are not unfavourable.

Remedial Treatment consists of the administration of salines and diuretics. At the
commencement of an attack considerable relief may be given by an emetic or mild pur-
gative. Digitalis may be required for the heart, and paraldehyde for the sleeplessness.

The BeUpdng Fever of Africa is an acute specific disease due to a spirochaete intro-
duced into the blood by the bite of a tick. After three or four days' severe fever the
temperature falls, and may not rise again for one to three weeks, but usually about the
eighth day all the symptoms return. Intermissions and relapses follow with more or
less regularity from &Ye to eleven times, leaving the patient much reduced in strength.
During the attack the spleen is enlarged and the spirochsete abounds in the blood.
Death may occur, especially in Euroj o:-ns. The diagnosis can be made only by
finding the parasite. Treatment is symptomatic.

612 P YREXIA [ S§ 875, S76

BeUpsing Fever of India. — The Symptoms are similar to those of the European type,
but usually there are no rigors. When the fever subsides the patient is often collapaed,
and may resemble one suffering from cholera. There aro as a rule at least three
pyrexial periods, and there may be more. The mortality is about 18 per oent.

Etiology. — ^The disease is caused by the spirochsBta oarteri (Manson). It certainly
can be conveyed by bugs, but its usual mode of transmission has not been determined.

The Relapsing Fever of America is caused by the spiroclueta novyi Schellaoh. The
mode of infection is not known. The symptoms, etc., are very similar to those of
the European type.

I 875. Thermic Fever or Heat Stroke (Synonyms : Siriasis, Heat Apoplexy, Heat
Asphyxia, Sunstroke, Coup de Soleil) is one of the numerous varieties of tropical fevers
about the pathology of which we know but little. Syncope due to excessive heat is
not the same condition.

Symptoms, — ^The onset is usually sudden, during or after exposure to high tempera-
turo with moisture. In some cases there are a few days prodromata, consisting of
headache and malaise. Then a short stage of delirium rapidly sots in, and is imme-
diately followed by coma and high fever ( 108° to 109° F. ). During the stage of delirium
the patient is restless, with muscular twitching and spasms. The stage of coma is
marked by a very hot skin, rapid pulse, flushed face, heavy or stertorous breathing,
and contracted pupils. In most cases death occurs a few minutes or hours after the
onset of insensibility.

Diagnosis, — The coma of urosmia, diabetes, and drugs (morphia, alcohol, etc.). Lb
known by the absence of high fever. In the coma of cerebral hoimorrhage into the pons
fever may occasionally be present, but it would not precede the onset of coma. The
comatose form of mdaria is recognised by finding the parasite in the blood, and an
enlarged spleen.

Etiology. — ^All ages and sexes may suffer. It is predisposed to by intemperance,
fatigue, malaria, overcrowding, and weakness of any kind. Sambon pronounces it to
be due to a germ which requires for its action a high temperature. It is frequent
amongst those who have to perform long marches in the sun of tropical or subtropical
climates.

Prognosis. — ^The case-mortality is about one in four. Most patients die from
failure of respiration after the onset of coma. Favourable cases terminate by crisis,
and make a rapid convalescence. Much depends on prompt treatment.

Treatment. — ^The indication is to reduce the temperature at once, if possible without
the use of drugs. Lest malaria be also present, it is best in malarial countries to give
a hypodermic of quinine (7 grains) at once, and to repeat it every four hours. In order
to reduce the temperature the patient must be laid on a stretcher, with a sheet covered
with ice placed over him. Iced water should be run over him till the thermometer
in the rectum falls to 102° F., or, if much hyperpyrexia be present, to 104° F. Then
he should be wrapped in blankets, and stimulants given. Avoid strychnine beoaueo
of the tendency to convubions.

Several forms of fever due to Tick-Bites have been described, the best known of
which are described below.

§ 876. Rocky Mountain Fever (Synonym : Kocky Mountain Spotted Fever). — Symp-
toms : During the incubation period of two to eight days irritation and pain may be
experienced in the tick-bites. The fever often commences with a slight rigor, and
the temperature rapidly rises to 103°, and later to 105° or even 107° F. ; the maximum
is reached by the fifth to the twelfth day. About the third day the eruption appears in
the form of macules on the wrists and ankles, which rapidly spread all over the body,
including the face, and may become hsemorrhagic. The spleen is palpable and tender,
and there may be slight bronchitis and sore throat. Pneumonia is a not uncommon
complication. Gangrene of the fingers, etc., may occur. The fever in favourable
oases falls by lysis ; if it remains high the patient falls into a typhoid state and does
not recover.

Etiology. — This fever only occurs in certain parts of America, and always at a height
of at least 3,000 feet. It occurs during June and July and chiefly in those whose work
or pleasure takes them into the woods and uncultivated regions, where the ticks
abound at this time of year. The tick-bite conveys to the blood an unknown virus.

§876] ROCKY MOUNTAIN FEVER— KALAAZAR 613

Diagnosis. — Tho disease resembles typhoid and typhus. From the former it is
differentiated by the eruption, but it cannot always bo distinguished from the latter.
Exposure to infection by residence in an infected region must be taken into account.

The prognosis varies in different localities. In Montana the mortality has been as
high as 90 per cent., and in Idaho as low as 2| per cent. Prophylaxis consists in the
avoidance of the places which are tick-infested and by destroying the latter by the
application of ammonia, turpentine, etc. The bite may be cauterised with pure
phenol.

KaU-Anr is a disease found in China, India, Assam, and the northern part of
Africa, due to the presence in the body of the Leishman-Donovan bodies inoculated
by the bite of bugs.

Symptoms. — (i.) The disease starts with rigor and vomiting and fever which is usually
remittent, but may be intermittent, and lasts for some weeks. (iL) The liver and
spleen enlarge at the same time, (iii.) After an afebrile period irregular pyrexia
appears, of an intermittent type, which lasts on and off during the whole course of thf*
disease, (iv.) Emaciation ensues, which makes even more apparent the enlargement
of the abdomen with large liver and spleen, (v.) The patient has an earthy pallor ;
bleeding from gums and nose may occur, and, later, cedema and ascites, (vi.) The
blood ^ows little diminution of the rod cells, and leucopenia (1,000 or 2,000 per
oubio millimetre), with especial decrease of the polymorphonuclears. The disease is
fatal in one to two years in over 90 per cent, of the cases ; death occurring usually
from intercurrent maladies, especially dysentery.

The diagnosis is made by finding the parasite by liver puncture, or in the later
stages, in the blood. As water destroys the parasite the syringe and needle used for
the puncture must be dried in alcohol and warmed before use. The fever of kala-azar
does not yield to quinine as does malaria.

Treatment is not satisfactory. Very large doses of quinine do good (60 grains).
Atoxyl has been tried.

Phlebotomni FeTer^ (Synonyms : Simple Continued Fever, Pappataci Fever, Three
Days* Fever) is a fever affecting new-comers in the summer months in Herzegovina,
Dalmatia, Malta, Crete, Egypt, and parts of India.

Symptoms. — ^After an incubation period of four to seven days the patient has a rigor,
followed by severe headache, fever, and severe pain in the eyeballs and brow, back,
and calves of the legs. The eyes are congested, the face flushed, the tongue foul.
The fever ends after seventy- two hours. The disease is seldom or never fatal, and one
attack confers immunity.

Etiology. — ^The poison reaches the blood of man by the bite of a sandfly, the phlebo-
tomus papatasii, which abounds in the summer in the above-mentioned districts.
The nature of the poison is unknown ; it can pass through a Pasteur filter.

Treatment is symptomatic. Prophylactic treatment is difficult. The insect bites
at night, and is so small that it can penetrate the meshes of a mosquito net. It
dislikes sunlight and wind.

Bat-Bite Fever has long been described in Japan as occurring after the bite of a rat.
and was known by the history of a bite, a purple-coloured eruption, and attacks of
fever at long intervals. Recently, however, cases^have been met with in this country. 2
(L) There is a history of a rat- bite which heals slowly ; (ii.) four or five weeks after
there is pain and swelling at the situation of the bite, with fever, which may reach
106** F. ; (iii.) the fever recurs at intervals of days, weeks, or months. It may last
only a diay, or about a week, assuming an intermittent type ; (iv.) the fever in some
oases is accompanied by an erythematous eruption ; nothing is found in the blood
beyond a moderate leucocytosis. A blood parasite has recently been described in Japan.

Japanese Biver Fever (Synonym : Tsuteugamushi Disease). — The symptoms re-
semble those of Rocky Mountain Fever. On the first or second day there is a tender,
non-suppurating enlargement of the lymphatic glands, and near some groups there are
found one or more small black scabs surrounded by an inflammatory redness. On the
sixth or seventh day a papular eruption appears first on the face ; it spreads down-
wards, and lasts four to seven days. During the second week of the fever the scab

1 Dr. F. M. Sandwith: Clin, Joum., Dec. 6, 1911.

^ T. J, Holder: Qtuirierli/ Joum, of Medicine, Jan., 1910.

614 PYREXIA [§377

falls, leaving a ptinched-out ulcer, which may take some weeks to heal. Gonjuncla-
vitis is present early in the disease.

Etiology, — ^The disease occurs only in certain flooded valleys on the west coast of the
largest island in Japan. It may be transported by com, hemp, and other articles.
It is due to the bite of a tick which bores into the skin. A sporozoon has been
found in the blood and organs.

The diagnosis is m€ule from a consideration of the locality and by the skin lesions.
Otherwise it is indistinguishable from typhus and Kocky Mountain fever.

The prognosis is good in the young, and in second and third attacks. The mor-
tality is 30 per cent. Treatment is symptomatic.

Pfittacoiis is a disease epidemic among parrots, due to a bacillus of the coll group. It
is conveyed to man by handling the birds, and is seldom communicated from man to man.

Symptoms, — ^The incubation period is seven to twelve days. The onset is acute or
gradual, more usually the latter. The temperature rises to 102*^ to 104° F., and the
spleen is enlarged. Rose-coloured spots appear on the skin, and the patient falls
into a lethaigio semiconscious condition, in which he may remain several days. The
disease may terminate in recovery after two or three weeks. An atypical pneumonia
is a common and fatal complication ; the death-rate is 35 per cent.

The diagnosis is made from the presence of sick parrots in the house of a patient
affected with an obscure fever and pneumonia. The bacillus may be recovered from
the sputum.

Treatment is symptomatic. Prophylaxis consists in the quarantining of all parrota
imported from South America and the destruction of all found to be infected, as well
as of their cages, etc.

Hay Fever (Hay Asthma), especially the constitutional variety, Dyientery, and
Cholera, give rise to a certain amount of pyrexia of a continued type.

Hay Fever (§ 130) is recognised by the violent attacks of sneezing.

Dysentery (§ 219). — Acute dysentery is sometimes attended at the onset by some
degree of pyrexia, but much the most important symptom of this disease is diarriiosa.

In Cholera (§ 220) the abdominal cramps, collapse, and diarrhoea are the leading
symptoms. Ihiring the collapse stage the temperature may be as high as 105° F.
in the rectum, although in the axilla and mouth it is subnormal. In the reaction
stage, if the patient lives, there is usually a degree or so of pyrexia lasting from a week
to a fortnight.

Finally, there are several diseases which in their typical forms belong to Group III.,
or, belonging to Group I., are seen perhaps before or after the eruption comes out,
which may present pyrexia of a continued type. It is well in all cases of difficulty or
doubt to remember this, and to pass in review the members of all three groups.

OROUP III. INTERMITTENT PYREXIA,

§ S77. In this group of diseases the pyrexia is of an intermittent (or
remittent) type — t.c, the temperature drops at regular or irregular
intervals to normal (or nearly to normal). This group is distinguished
from Group I. by the complete absence of eruption. It is distinguished
from Group II. mainly by the wide variations of the temperature.

Common,

I. Malaria $ 378

II. Latent tuberoidosis . . § 381

III. Visceral syphilis . . • • § 382

IV. Acute septicsBmia . . § 383
V. Subacute septic conditions § 384

VI. Knteric fever (some cases)
and occasionally influ-
onza . . . . . . § 364

Rare,

Malignant endocarditis . .

. § 30a

Lymphadenoma . .

. § 408

Pernicious anaemia

. § 403

Leukaemia

. § 407

Ophim habit

. § 627

Trypanosomiasis . .

. § 386

Trichinosis

. S 444

§878] INTERMITTENT PYREXIA— MALARIA 516

The clinical investigation of these diseases is often attended by considerable diffi-
culty. Malaria, which may be regarded as the type of this group, is essentially a
paroxysmal pyrexia, each paroxysm having three stages (cold, hot, and sweating),
and each paroxysm being usually separated by one or more days' interval of health,
Ttjbebcttldsis and Syphilis have a daily rise and fall, and are good examples of
regvlar diumally intermitting pyrexia. Acute Sbfticsmia, on the other hand, is
noted for the irregvlar character and wide range of its temperature and the severity of
the rigors. Chbonio Septio Conditioks occupy a position midway between these
two t3rpe8 — regular and irregular intermitting pyrexia. In a given case of inter-
mitting pyrexia which has arisen in a tropical or subtropical climate malaria is
probable, but in England the commonest cause is probably latent tubercle. The
Sebum Reactions aid us to some extent in the diagnosis of this group.

Turning to the rarer diseases, which must always be kept in mind. Malignant
Endocabditis is chiefly remarkable for the long course it may run. In Lybiph-
ADENOMA we find the enlarged glands ; and in Pebnicious An>bmia the patient is a
male, and the skin is very sallow, and the blood is characteristic.

It follows therefore that if we have a patient's temperature chart
before us, and it shows definite intermissions or remissions, the disease
will belong to one of three sub-groups :

A. Regulab Intermittent Pyrexia, with one or two days' interval,
which contains only one disease — Malaria § 378

B. Regular Intermittent Pyrexia occurring daily, such as Tuber-
culosis, and Visceral Syphilis §§ 381 et seq,

C. Irregular Intermittent Pyrexia, such as Septicaemia, and other
pyogenic processes §§ 383 et seq,

§ 878. Malaria (Synonyms : Ague, Intermittent Fever, Remittent
Fever, Jungle Fever). — ^Ague is a non-contagious fever, occurring in
paroxysms with complete intermissions, due to the malarial parasite
introduced by the bite of a mosquito.

Symptoms. — As a rule the fever comes on suddenly without warning.
The period of incubation varies considerably. Sometimes there may be
none at all ; sometimes it is not more than a few hours ; while in some cases
there may be an interval of months or years after exposure before the
disease develops. Sir Patrick Manson gives two to two and a half years
as the limit for tertian ague, and two to three years for quartan. A
paroxysm has three characteristic stages. First there is a cold stage, in
which the patient shivers or has a rigor, and feels cold, though the tempera-
ture is elevated three or more degrees ; the skin looks cold, sometimes livid,
and the nails are blue. It lasts from one-quarter to two hours, or so, and
is followed by the hot stage, in which the temperature goes up 103° to 106° F.
It begins with flushing of the face, and is attended by headache, pains in
the back and elsewhere. It lasts three or four hours, and is followed by
the sweating stage, in which the perspiration is so profuse that the bed-
linen may be soaked. This stage lasts one or two hours, and is accom-
panied by a fall of temperature. The spleen enlarges during the attack.
The stages may be shorter or longer. The sweating stage is followed by
an interval, during which the temperature is normal, or subnormal, and
the patient is fairly well, except for great lassitude and indigestion. In the

510 PYREXIA [5t78

commonest type of the disease (Tertian Ague, Fig. 99), there is ao interval
of about twenty-four hours between the paroxysms, which, if untreated,
may recur for weeks.

Varieties of Malaria. — Malaria fever may vary in two ways : (a) Accord-
ing to the duration of the interval between the attacks, or (b) according
to the intensity ; both of which probably depend on the species of the
Plasmodium, (a) There are three types of periodicity (Fig. 99) : (i.) Quo-
tidian fever, in which the paroxysm occurs daily, is rare, and due to a
double infection o( tertian or quartan fever; (ii.) Tertian fever, in which
attacks occur every other day; and (iii,) Quartan fever, in which the
attack occurs every third day. Various compounds of these occur.

FiB. OT.— Ttpks 0
thJ

(6) Pernicious malaria is the term given to the severe forms, the chief
varieties of which are (i.) the comatose, in which the patient suddenly passes
into coma ; (ii.) the hyfer'pyrexial, in which the temperature rises suddenly
to 107° or 1 12° F., and death occurs in a few hours ; (iii.) the algide, which
resemblea the algide stage of cholera; (i v.) Remittent Fever; and(v.)HEemor-
rhagic Malaria, or Blackwater Fever. The CBStivo-autumnal parasite is
present in the pernicious forms of malaria.

Diagnosis. — Malaria is rarely mistaken for other diseases ; but the
other disorders attended by intermitting pyrexia about to be described
are very frequently mistaken for malaria. Clinically, this mistake would
be avoided if it were remembered thai malaria of true quotidian periodidtg —

J 878] MALARIA 617

daily recurrence — is very rare^: and that tertian or quartan periodicity is
absolutely pathognomonic ; it occurs in no other disease. In leprosy and
all the diseases mentioned below the intermission is daily. Therapeutically,
the diagnosis may be established by full doses of quinine ; if this be given
intramusciJarly, and fail to relieve, the attacks are certainly not malarial.
The microscopic recognition of the parasite in the blood requires considerable
experience, but it is always possible to find it in blood-films, provided the
patient has not taken quinine for several days ; this is an essential part of
the examination, and is, of course, positive evidence. Enteric fever and
many other conditions belonging to Group 11., when occurring in a malarial
subject, are apt to assume a malarial or intermitting type of pyrexia.

Etiology. — Age and sex have no real influence. The disease' is most
prevalent at the latter part of the rainy season. One attack predisposes
to a second one ; indeed, when once a person has contracted malaria, he
is always liable to it for many years. The exciting cause of malaria is a
parasite — the plasmodium (see § 399). It is introduced into the blood of
the patient by the bite of the anophdes, a mosquito, which serves as an
intermediate host for the parasite. There are three forms of parasite
known — (a) the tertian ; (6) the quartan ; and (c) the aestivo-autumnal.
The type of the fever depends upon the time required for the sporulation
of the parasite, .since the onset of the pyrexia corresponds to the day on
which sporulation is completed. Thus the plasmodium of tertian ague
completes spore formation in two days, that of quartan ague in three.
The disease is endemic in certain districts, which are called malarial, and
these districts are always situated in tracts of country which are marshy,
or where the soil is moist and covered with pools of water and decom-
posing vegetable matter. It is still to be met with in Italy and North
America and in some parts of England — e.g., Cambridgeshire — but it is
chiefly in the uncultivated tracts in India, Assam, Africa, Asia, and South
America that the disease is prevalent. It disappears from a district when
the soil is drained and cultivated. Standing water, especially in puddles,
seems to be a necessary condition, together with a moderately high tem-
perature. Malaria was always observed to keep close to the ground, and
its spread was known to be interrupted by a tract of water, especially
salt water, or by a grove of trees. It was known that change of wind
would bring malaria from a distance. Persons newly arrived in a district
were especially prone to contract the disease. These and other curious
data have been known for many years, but remained without explanation
until it was proved by Manson, Ross, Nuttall, and others, that the disease

^ The only fallacy to this statement occurs in those cases when both the tertian and
the quartan parasites affect tiie patient at the same time, and thus give a partial
semblance to quotidian attacks. But even then the pyrexial attacks are not really
quotidian, as may be seen from the following diagram. Supposing '* a '* represent
the attacks of a tertian parasite, and ** b " those of a quartan parasite, there would be
one day's interval after at longest three days' pyrexia, viz. :

|a , bja |a| ,a, b .a| ,a 1

518

PYREXIA

t5»7»

is conveyed, and is introduced into the blood of man, by the mosquito

(Fig; 100).

Prognosis, — Death usually occurs from complications, without which
malaria is not a very fatal disease. The most favourable type of case is
that in which the pyrexia runs a typically intermittent course. The

gravest, and happily the rarest, is that
form in which the pyrexia is continued
or only remittent. Coma or delirium,
hsemorrhage from the stomach or bowels,
and choleraic diarrhoea with cramps
are unfavourable complications, and if
collapse sets in after the hot stage a fatal
termination is usual, (i.) Great weak-
ness and ansemia are common results of
the disease, and in time, especially if
untreated, the patient develops the
typical cachexia of malaria. Pigmen-
tation of the skin is a marked charac-
teristic of this cachexia ; the distribution
of pigment is general, but is especially
evident around the eyes.^ This is doubt-
less accounted for by the deposit of
blood-pigment granules which are so
constantly found in the blood, (ii.) En-
larged spleen—" ague-cake " (§ 262, V.)
— is a usual sequence, and rupture of
the organ occasionally takes place,
(iii.) Jaundice, due usually to hepatitis,
is one of the more serious complications,
and the liver after many attacks becomes
enlarged. Heematogenous jaundice, due
to the destruction of red cells, may also
follow fever of long duration.

Treatment, — Quinine is a specific for
this disease ; it may be given by the
mouth or by the rectum. For oral
administration it should be given in a
powder, or freshly dissolved in a mixture,
as pills and tabloids are useless if hard
and insoluble. The bisulphate and hydrochloride of quinine and euqui-
nine are good preparations, 5 to 10 grains thrice daily after meals.
During fever as many as 20 to 30 grains daily may be given. An aperient
should be administered at the onset. In the mild tertian and quartan

^ On one occasion when I joined a passenger ship from the East this periorbital
pigmentation was so marked in one of the passengers that I thought he must have
been fighting, until I learned that he had been a victim of malaria.

Fig. 100.— MosQUlTOKS settling on a
wall. — There are two chief types of
moBquitoes — ^Anopheles and Culex —
easily differentiated by their atti-
tudes when resting upon a wall.
Anopheles is the more dangerous
one, and is recognised by its spotted
wings and its tilted attitude. Its
larve lie flat on the surface of
puddles, and move along the surface :
whereas Culex larv» lie more per-
pendicularly, and if disturbed rush
to the bottom of the pool. Ano-
pheles larvse are found in puddles
which contain algs and which are
too large to be dried up in a week
(time needed for the mature insect
to be hatched). They are not found
in pools which contain minnows, nor
in rapid streams, nor in shallow rain
pools that are easily dried up. Kero-
sene oil (about 3i. to a pool of 1 square
yard) killed all larv® in six hours.

§§879,880] REMITTENT FEVER 519

fevers, the drug should be given four hours before the attack — i.e., before
sportdation. Where prompt action is required (as in the pernicious
form) the quinine should be administered intramuscularly or intra-
venously; in the pernicious form 15 grains of quinine are given.
Intramuscular injections are also used when there is much gastric dis-
turbance. Sterile ttes are procurable containing the correct dose of the
drug dissolved and ready for use for intramuscular or intravenous injec-
tion. In algide conditions, hypodermic saline injections are called for.
Warburg's tincture, which contains a small proportion of opium, has been
found to act better than quinine in certain cases. The drug should be
continued in small doses for some time after the subsidence of the fever.
For the resulting anaemia, iron and arsenic are necessary. For the " ague
cake " red iodide of mercury ointment should be rubbed in over the en-
larged spleen. The indications for prophylactic treatment are based
upon the etiology. In order to get rid of the breeding-groimds of the
mosquito, marshy tracts, swamps, and roads must be drained ; cisterns
and wells must be screened, and kerosene oil should be poured upon all
stagnant pools. High sites should be selected for sleeping. Mosquito
nets are essential, and wire netting for rooms and houses can be obtained.
Quinine should be taken (5 grains daily) as a matter of routine by those
who live in the mosquito-infected districts.

§ 879. Bemittent Fever (Synonyms : .^tivo-autumnal Fever, Jungle Fever, Per-
nicious Malaria, Continuous Malarial Fever). — Remittent fever is a variety of malaria,
due to the sestivo-autumnal parasite. There is a protracted hot stage, and no
apyrexial intermissions. The cold stage is either absent altogether or is only marked
by a chilliness. The pyrexia continues, with slight daily remissions, for a week, two
weeks, or more. In some forms there is a tendency to the typhoid state (" typhoid
remittent fever "). In other forms gastric symptoms are prominent, together with
marked jaundice (** bilious remittent fever "). Sometimes there is great prostration,
with hsemorrhages, and this form is followed by extreme anaemia. The Diagnosis
from yellow fever on the one hand, and enteric on the other, may be impossible with-
out an examination of the blood and the discovery of the parasite. In yellow fever
albuminuria is present, and the temperature falls in three or four days. Ilnteric
gives the Widal reaction. The Prognosis is often unfavourable. It is especially
bad when the remissions become less marked, and the typhoid state supervenes.
Unfavourable symptoms are collapse, delirium, and coma. In this variety rapid
action is called for, and therefore quinine must be administered intramuscularly, or,
better still, intravenously.

§ 880. " Blaokwater " Fever (Synonym : Hsemoglobinuric Fever), so named from
the colour of the urine, is a form of malaria possibly due to a special plasmodium,
and occurs only in countries where remittent fever is general.

Symptoms. — In a typical attack the onset is marked by rigors, and the temi>erature
ranges from 103** to 105° F. The urine which is passed is of a dark red colour, turning
to black, due to the presence of haemoglobin ; it is scanty in amoimt and of high
specific gravity. There is bilious vomiting, which may be extremely severe, and
accompanied by uitenso jaundice. As the fever falls, the urine clears ; then a new
paroxysm of fever may set in, with a return of the haemoglobinuria. The liver and
spleen may be enlarged. During the paroxysm there is great destruction of red bleod
corpuscles, and the blood shows poikilocytosis. Etiology. — ^This fever is endemic in
the tropical and subtropical regions of America and Africa. What determines the
onset of the paroysm is not known. Some have thought that the haemoglobinuria is
related to the administration of quinine, but only in patients who have suflFered
previously from malaria.

520 P Y RE XI A [ §§ 881, 881a

Diagnosis. — ^This disease may be mistaken for yellow fever. Malaria parasites arc
not found during, but can be found before or after, an attack.

Prognosis, — ^The case-mortality is 25 per cent. Frequent relapses are certain to
occur if the patient remains in the endemic district, unless he succeeds in protecting
himself from recurrence of malaria. Even if he return home, he is liable to have
attacks of hemoglobinuria, though these may be accompanied by little or no fever.
In severe cases there may be profound prostration, with all the symptoms which accom-
pany a profuse haemorrhage. Death may result in this way, or from syncope, or
collapse. There may be suppression of urine, and death with symptoms of uraemia.

Treatment. — Except during the attack, quinine should be given in gradually in-
creasing doses, beginning with gr. i. t.i.d. Saline solution must be given per rectum,
intramuscularly, and if necessary intravenously. The patient must be kept at rest,
and water must be freely given.

§ 381. Latent Taberculosis. — Tuberculosis is said to be latent when the
usual physical signs or local manifestations are wanting. In all cases of
unexplained intermitting pyrexia in this country, one of the first things
to be suspected is tuberculosis in some part of the body. It may be very
deeply seated, but it is a useful clinical axiom to remember that no active
tuheraulosis can exist in any fart of the body without the occurrence of a
daily ifUermitting pyrexia. Moreover, the degree of the fever is a fair
indication of the activity of the process. The chart is a typical one ;
the temperature drops each morning to (about) normal, and rises each
evening one, two, or more degrees, occasionally vice versa. The physical
signs may be altogether wanting, and the patient, perhaps, only seeks
advice on account of the weakness, dyspepsia, and other vague symptoms.
Such a condition may go on for weeks without any local manifestations,
as in the cases referred to under Tuberculous Meningitis. The lungs,
kidneys, peritoneum, and various organs may be affected. (1) The com-
monest locality in adult life is the lui^gs. In this case physical signs usually
appear which resemble bronchitis or simple pulmonary congestion, for
which diseases it is apt to be mistaken (§ 83). (2) The meninges, peri-
toneum, and other serous membrane, are perhaps the commonest positions
in childhood in which tubercle may be deposited without definite signs.
(3) In the kidney y tuberculous pyelitis may be readily overlooked, and in
suspicious cases the urine should be carefully examined for traces of pus
and tubercle bacilli (§ 305). (4) Tubercle may also be latent in other
situations, such as the cranium, spine, intestines, and other viscera ;
and, finally, the tuberculous process may be generalised, and give rise
to the condition known as Acute General Tuberculosis. In the diagnosis
of tuberculosis we may seek the aid of certain blood reactions (see § 94).

§ 881a. Acute General Tuberonlosii (Synonyms : Acute Miliary Tuberculosis,
Typhoid Tuberculosis) may be of the meningeal type, usually known as tuberculous
meningitis, and described under that title ; of the pulmonary type {vide § 83) ; or of
the typhoid type, with which we are now concerned. It is characterised by inter-
mitting pyrexia, prostration, and a tendency to the typhoid state — due to a generalised
infection of the body by the tubercle bacilli.

Symptoms. — (1) The onset is insidious. The patient complains perhaps of nothing
but lassitude, which is attended by feverishness of a typical intermitting type, and
perhaps bronchial catarrh. The temperature each morning may be normal, that in the
evening raised one or more degrees. The in verso typo — t.e., a lower temperature in
the evening than the morning — is said by some to be more frequent in this than in

StSlo] ACUTE GENERAL TUBERCULOSIS 621

other foiniH of tuberouiosuJ Id very rare casei the highest daily tempDratuTD does not
riae above normBl. The patient coinp]aiiiB of lasBitutie, which gradually increases,
and in the concse of a fow wncka ho has wandering, muttering delirium, at tirat only at
night. Maniacal delirium is rare. The typhoid state supervenes towards the end.
(Z) The cespiration is always increased in frequency. The pulmonary aigns, which are
generally present, have boon mentioned (f 83). (3) As a rule there are no marked local
manifestations, but. according to the chief seat of miBchief. various other signs may be
elicited, such as paralysis of the cranial nerves, peritonitis, pleurisy. The spleen is
nearly always enlarged.

Diagnonit. — (I) The prusence of bacilli in the sputum is pathognomonic, and these
should be looked for repeatedly in all cases of " bronohilia "attended by an intermitting
pyrexia, e8i>ecially in young adulta. Most cases of acat« miliary tuberculosis in the
early stage are admitted to hospital as bronchitis, in the later stages as enteric fever.

Pig. 101.— AOCTB HlUAKT TuBBBonuMls. — Ow. W , st. Corty-ninc, admitted to Iho Pad'

dlngton InRrinu)', July S, and dl*d July IS, 1888, HeVBn weeks' hlatoiy of vsgne Uloeu
belors odiuiHion, durlns which time there was profiua hsmopti'ili on one occulon. The
■Igns In the cheet wero very iDdeAnJte during lire. AflcTdeatJi tbe lunss were aponely ttuddsd
witb miliary tubemulosii. Tbe liver and peritoneum were also dotted with tlay tnberclei,
hardly visible to the naked eye.

(2) The course of the disease may bear so close a resemblance to enCmc /ever that
Niemeyer (before the discovery of the tubercle bacillus) stated that these disorders
might be indistinguishable until the patient reached the dead-house. The Ehrlioh-
Diaso reaction oooiirsin both enteric and acute tuberculosis, but not tbe Widal reaction ■
Choroidal tubercles are sometimes visible on ophthalmoscopic examination, and if
present aettle the diagnosis.

Etiology. — The disease is doe to a general dissemination of the tubercle bacilli
throughout the body. These may have been introduced from outside, but far more
frequently can be traced to some chronic or subacute focua in the patient himself,
such at an old caseous or fibroid gland which appeared to be dead, or an old quiescent
spot in the lungs or elsewhere.

Prognotu, — The disease is uniformly fatal in the coarse of four to eight or mors
' Aooording to Itoinhold (quoted by Osier, he. cil.), 18 per cent, of tubenmlosij
csaes present an inverse temperature.

StS PYREXIA [!S8S

weeks. Death occurs by coma, sometiiiieB by pulmon&ry or other compliostioDs-
The height and range of the temperature ia a fair moasure of the virulence and activity
of the morbid prooeea.

Trealmtnt. — In auch widespread mischief do truatment ie of any avail. As regards
prevention, it should always be remembered that convaleeoence from palmonaTy
tuberculosis shonld bo very thoroughly re-established before treatment ia stopped.

§ 882. Tiscersl Syphilis.— It is now geuerally recogiiisud that syphilis is
a specific contagious diseaae like small-pox. There are two difEerent stages
of syphilis at which int«rmittiiig pyrexia may occur, (a) At the first
development o£ the piimary roseolous eruptioQ fever there may be some
elevation of temperature.* This in generally overlooked, but at other
times it may he accompanied by thirst, loss of appetite, and shivering.

Pin. 102.— ViscEHtL SVPUILI9. AdhIs L-— , Kt. ilxty-iii, admitted to the TaddiDgtoQ Inarmacy,
July 2S, ISSa (?). The temperatuie eubaided under Iodide Id large doaes, but th« ultlnutelf
died of eibanitlOD and hypostatic pDenmonla, P. U. — Ouminata of liv«r and bonM, hyper.
tiophic drrboals, wldeeptead flbroali at organs.

It always occurs within sixty-five days of the date of the infection, and
ia only present if no mercury be given, {b) In the later secondary and
tertiary stages of the disease an intermitting pyre.\ia may occur in con-
nection with syphilitic periostitis, or gummata of the internal organe.'

' This has only been generally known uf lat^j years, but it was first pointed out by
Guntz in 1865, and called " general sypbilitio fiiviT." Lancereau^ also pointed it out
in 1S66. and stated that it much resembled quotidian ague. He referred to several

of the liver in a lad of siiteen, in whom the temperature went up every a
or 3", the causa being overlooked until interstitial keratitis was discovered, and iodide
was given (Clin. Soo. Trans., vol. xix.). The author has records of six similar oases
in whieh tha leading aymptoms were iotermitting pyrexia, anffimia, and aigna referable
to the liver or spleen, all of which rapidly disappeared under iodide (soo also Clin.
Jourit.. Deoembur 1 , 1897, p. 87).

§888] ACUTE PYJBMIA 623

This is a not infrequent occurrence in the course of clinical work, and
syphilitic lesions of this kind are always to be suspected in cases of pro-
longed intermitting pyrexia, especially if it be attended by ancemia. The
morning temperature is normal, but in the evening it goes up one, two,
or more degrees (Fig. 102). There may also be rigors, nocturnal sweating,
and paroxysms of pain in the joints, imrelieved imtil iodides are given ;
then the symptoms speedily subside. In obscure cases careful investiga-
tion should be made of the eyes, liver, ribs, clavicles, and other bones,
and iodide of potassium tried.

§ 883. Acute Pysemia, or Septicaemia/ is a disease characterised by a
wide range of temperature, accompanied by rigors and sweating, due to
the direct infection of the blood — ^usually through some breach of surface
in skin or mucous membrane — by a pyogenic microbe.

The Symptoms are (1) pyrexia, which runs a very characteristic course,
and is distinguished from all other diseases not of septic origin by the toide
and very irregular range of the temperature (Fig. 103). The remissions
may occur several times a day, and have not the diurnal regularity which
marks the two preceding classes of disease (§§ 381 and 382). There may
be as much as 6° or 7° difference between the temperature in the course of
a few hours. When at its highest point, the temperature is accompanied
by rigor, followed by very profuse perspiration and a rapid fall. The
pulse is rapid and compressible, and the prostration and lassitude are very
marked. The mind is clear at first, and remains so for a considerable time,
but towards the end there is a tendency to the typhoid state. (2) Nausea,
vomiting, and diarrhoea are common, the skin is sallow, and there is often
jaundice. (3) Later on in the disease emboli may occur in different parts
of the body, especially in the lungs, where they give rise to a generalised
congestion and patches of pneumonic consolidation or gangrene (as in
the case given in Fig. 103), and in the liver and spleen, and deposits of
pus may occur in or aroimd the joints or in other parts of the body. The
serous cavities may also contain pus, constituting empyema or pyo-
pericarditis. The occurrence of albumosuria is an indication of a focus
of pus in the body, and this may be an aid to diagnosis ; so also are the
leucocytosis and other changes in the blood (Chapt-er XVI.).

Acvie Osteomyelitis (or, as it used to be called, Acute Periostitis or Acute Necrosis)
is a pysemic process which may set in very suddenly, usually after an injury to one of
the superficial bones, generally the tibia. In children there may be no history of
injury. The diagnosis is easy when the tissues round the diseased bone are swollen,
but during the first day or two of the disease pain is often complained of near a joint,
and may lead one to diagnose rheumatic fever.

The Diagnosis of septicaemia is easy when there is an external wound

or abrasion, and should never be difficult on account of the wide variation

of the temperature, coupled with the rigors and the sweats. The chart of a

typical acute case is like nothing else. When due to some internal cause,

^ There is still some confusion in the use of these terms, but for clinical purposes
thoy may be regarded as synonymous. In former times, when localised deposits of pus
occurred, the former term was generally applied ; when these were absent, the latter.

624 PYREXIA [IS8S

it may resemble lualiguaat endocarditis, enteric fever, pneumonia, ague,
remittent fever, and acute rheumatism. But when carefully recorded
temperatures of several days are available, and a thorough examinatioD
of the organs is made, the diagnosis should not be difficult.

Etiology. — A cause — external or internal — for py»nia should always be
carefully sought. Among external sources, unhealthy wounds were, before
the introduction of Listerism, a prolific source of this disease, and the

Fig, 103. — AuiTK SEPTICEMIA (typicil Of an irregularly Intermitting pyreula).—

let. wx, udoiltMd to hoipltal, September 27, issi. She was taken 111 aomewbat inddeiily on

tlon. There were do pb)-airAl gigns excepting a (yelolLc brnlt aver the wbole caidlic area,
and aligtit ealusemeiiC of the spleen. On the SOt^ there wai rutty aputum with atraaki of
blood ; dulaees and crepltatlona over the right back. She waa dellrioiu Irom tints to time,
and died aomewhat auddenly on October 3. At the autopay pqa waa foond In the maatold
cella and alang thromboela aecondaiy to long-ataading middle aat diaeaae (ol which a hiitoiy
waa now obtained), inlarcta in the kidney, and pyo-pneumothorai aecondary to rupture of
one of the gangrenoua-loolclng abaceaaea of the lung.

patients in the surgical wards were decimated by it. A mere scratch is
sometimes sufficient for the introduction of the micio-oi^anisms, and
sometimes the most trivia! operations are followed by pysemia. The source
of infection may arise from some intertial condition. The internal sources
are very miraerous— sometimes it is caries, especially of the mastoid bone,
sometimes periostitis, or osteomyelitis, sometimes an ulcer and other
breach of surface in the mucous membranes. Ulceration of the biliary
passages and of the urinary passages are frequent sources of infection.

§888] ACUTE PYjEMIA 626

Special attention should be directed to the vermiform appendix (see
Appendicitis, § 175) and the uterus. Recent abortion, ferhafs criminally
procured, should always he home in mind when a young woman is admitted
with septiccemia. After recent parturition, the uterus resembles an open
wound, and offers a large surface for the absorption of the pyogenic
organisms ; hence the frequency with which septicaemia complicates par-
turition unless the most scrupulous cleanliness has been observed. The
disease is then called Puerperal Fever, or Puerperal Septic-«mia. When
the poison is derived from a previous case of puerperal septicaemia it is
specially virulent and fatal. Among the predisposing causes overcrowding,
bad ventilation, want of cleanliness, and other unhygienic and septic
conditions, are among the most fruitful.

Prognosis, — The course of septicaemia differs widely. Thus, on the one
hand, some cases of intense septic infection from a wound or parturition
run a rapid and fatal course of ten or twelve days, terminating in the
" typhoid state." On the other hand, cases in which apparently small
quantities of septic matter are constantly leaking into the general circula-
tion from some internal source may be indefinitely prolonged over many
weeks or months, the mind remaining clear the whole time. Such would
appear to have been the course of the disease in the patient referred to in
Fig. 104. There is, in fact, no definite line to be drawn between the acute
septicaemia now under consideration and the subacute and chronic septic-
aemia due to pent-up pus or ulceration described below (§ 384). Acute
pyaemia is a most serious and, if untreated, invariably fatal malady.
Death may occur either by the intensity of the poison (typhoid state),
asthenia,' or complications. The urUoward symptoms are a very high
temperature, frequent rigors, or cerebral symptoms. The most frequent
complications are (1) pneiunonia, which invariably occurs in severe cases ;
(2) pericarditis or pleurisy, which usually become purulent, and peri-
tonitis ; and (3) suppurative inflammation of the spleen, liver, and other
organs, consequent on the infective emboli ; (4) malignant endocarditis.
Among the sequelae in certain less acute cases which recover may be
mentioned a destructive form of arthritis.

Treatment. — The indications are (1) to remove the cause ; (2) to inhibit
the microbic toxin ; (3) to relieve the symptoms and maintain the strength.
(1) If the infection is derived from a wound or some accessible purulent
cavity — e.g., an abscess, an empyema, acute necrosis, etc. — this should be
promptly laid open, drained, and treated by antiseptic measures. Search
must be made for some internal cause — e.g., appendicitis — and this should,
if possible, be dealt with. (2) Thanks to the researches of modem
pathology, we are now in possession of an antistreptococcic serum, and
several cases are on record which have been rescued from death by this
means. As previously mentioned (and see § 388), several different bacteria
may produce the disease, and we must identify which is in operation before
we can employ the appropriate serum. The most frequent, when the
source is some purulent focus or abscess, is a form of streptococcus; The

626 PYREXIA [§884

great variety of forms of streptococci has proved to be the chief difficulty
in the serum treatment for septicaemia. It therefore usually happens that
the serum given is not antagonistic to the particular organism in opera-
tion, and a polyvalent is more likely to be successful than a monovalent
serum. Recently vaccines prepared from the organism obtained from the
patient's blood have been tried, with success if given early. (3) The
administration of quinine in large doses has some controlling influence over
the temperature ; antipyrin, antifebrin, and other febrifuges are also used.
The internal administration of antiseptics generally has not been found of
much use. Stimulants and concentrated nourishment are called for (see
also §§ 391 et seq,),

§ 884. Sabaonte and Chronic Septic Conditions (e.g,. Abscess, Ulceration,
etc.) also give rise to intermitting pyrexia. The various clinical conditions
met with under this heading are due to the absorption of some septic or
toxic material into the circulation. The possible sources of the sepsis are
very nimierous, and may be grouped into two divisions — (a) Absoess (or
pent-up pus) ; and (b) Ulceration (internal or external). Clinically, the
former is more acute than the latter, and, indeed, the former might be
called subacute, the latter chronic, septicaemia.

(a) Abscess (Pent-up Pus). — Pus never forms in any part of the body
— e.g.y in the pleura (empyema), in the liver (hepatic abscess), or elsewhere
— ^without the occurrence of "chills," "shivers," or "rigors," and an
intermitting or remitting pyrexia. Before the clinical thermometer was
invented, these shiverings (sometimes followed by sweatings) were the
chief symptoms by which the formation of pus was identified. When
there is fluid in the chest, for instance, and we do not know whether it is
serous or purulent, the occurrence of shivering or sweating will often
settle the question in favour of pus. The temperature in such cases
presents much the same chart as that in tuberculosis, though it has not
such regularly diurnal variations, and is more often accompanied by
shivering or rigors. There are considerable lassitude, debility, pallor
(though with a hectic flush on the cheeks), and more or less loss of flesh in
course of time. Albumosuria is us-ially present, and is a valuable con-
firmatory symptom. The blood should always be examined, and the
presence of leucocytosis with an increase in the proportion of polynuclear
cells will afford strong confirmation that pus is present.

Causes, — Abscess or pent-up pus in any position may produce these
symptoms, and careful search should be made for abscess of the liver,
spleen, or other organs, pelvic cellulitis, caries of the spine or mastoid
bone, appendicitis (Fig. 104), intracranial abscess, empyema, pyonephrosis,
etc. Pain is the chief localising symptom, but it may be wanting. On
giving free exit to the pus the pyrexia should rapidly subside.

(d) Ulceration of an Internal or External surface (including the
conditions known as " Hectic Fever," Hepatic, and Urinary Intermitting
Pyrexia) is always attended by some degree of intermitting pyrexia, run-
ning a. more chronic course than the foregoing. This fever also differs

S SU ] CHRONIO 3MPTI0 CONDITIONS 627

from the last in the usual absence of detinite rigors. Sometimes the
shivering may not amount to more than " chills down the spine " — thought
to be malaria, perhaps — and sweating which is hardly noticed. The morning
temperature is normal, or almost normal, and it is raised one or two degrees
some time during the day. Anemia and failing health are always present,
but here albumosuria and the blood changes just mentioned may be
absent. This kind of fever, due to prolonged suppuration, and attended
by chronic wasting, was formerly known (and is stil] among sui^ons)
as Hectic Fever (turiKos, Greek " habitual "). When due to a dischargmg
sinus — a sinus, for instance, connected with caries, or necrosis of a bone,
or a bed-sore — the cause is obvious. But the condition may also be set
up by ulceration of the intestines or any of the mucous membranes or
internal passages — e.g., the appendi^c (Fig. 104). It is called Urinartf

Fig. 10*. — CttKONIC Ptchia. Frank T , lot. thirty-one, hod had an attack of gonoirhcBi]

rheomatlaai two yean before, from which he had lecovered. The present illnsaa had come
on quite gradually a montli or bo before admlsaioa. StllTnisa nnd pain tn the JolDta being
the chief aymptomt, and the urethra beinR ahroMds normal, it was Tegaided aa a esse of
chronic rheuoirtlBm, thouKh nonp of the usual remodics had any sffeot. The Joints became
progieeslvely wone and thaugh he complained ol abdominal ruins from time to time attention
wai not directed to that cavity. He died eoiiie two months later suddenly from perforation
ol the appendix vermlformlB. A revien ut the case pointed to a chronlo septic procoa havldg
lla origiD In the appendix, and speeially ariectlng Jointa wbleb bad been prerlonaly dlaeaaad.

Fever^ when it arises from chronio ulceration of some part of the urinary
passages — e.g., when a stone is impacted in the ureter, or when the patient
has " stricture urethrre," or there is ulceration ol the pelvis of the kidney
(pyelitis). This cause may be suspected if there be a history of renal colic.
Similarly, Hepatic Intermitling Pyrexia (ulceration of the biliary pa8sa(,es)
may be suspected if there be a history of biliary colic. When the ulcera-
tion, due to gall-stones, is situated in the gaU-bladder, both colic and
jaundice may be entirely absent, and the patient complains of nothing but
the "chills" (§241).

§ 38S. The rarer causes of Intermittiiig Pyrexia are fully described else-
where, and, with the exception of trypanosomiasis, need only to be
mentioned here.

' Thet<

62S FY BEX I A Liau

Tnflnwm, Enteric, and other dianoses ditscHbcd in Groups I. and II.
are occaaionally attended hv pyrexia of an intermitting type (§ 367).

Ksls-AxsT has usually intermittent fever after the first period during
which there is fever of a remittent tvpe.

Bnteiic F«T«r during tho GibI two weeks of ils counte u sttendeil by typicsllj c<mi-
tinued pyreiia, bat in the concluding st^ge of the discMe the pyieiik gradukUy drops
each tnoming to aonnal, and the case maj be seen tor the first time in this stAge.
Under certain other circumBtADCes also the temperature may be intermitting — viz. :
(i.) In rsre inBtancoa it may commence with aymptoma of ague (Murchiaon) ; (IL) in
Teij mild cases the temperature may be intennittent ; (iii.) after lacrtjng a few daja,
the fever sometimes aborts and takes on an intermitting type. For the diagnosis of
the disease we now have a valuable guide in Widal's test.

Fig. lOS.— Hauohaitt OB ULCEBinvK EKOOCAHDrns Id a femala patient, «t. fwiy-two, who
wu admitted to the Psddington Inflnnary tn Ihe year 1890. Tbe three weeb ihown lUiutrat«
tiia cooru of ttw temperHture over a period ol tevenleen weeb. when she died. The chart of
anoUwr cais will be found In f 39a.

TarioDs local inflammttorr diMM«s, other than the septic conditions previonsly
mentioned, may at times bo attended by intermittent pyrexia. In cirrhosis of the
liver, for instance, a prolonged fever with daily oBOillations has occasionally been
observed.*

MaUcnant Endooardilii (Mdtiple Systemic Embolism) (} 39a) is always attended
by pyrexia of an irregnlarly intermitting type, sometimea with sweatings and hgois,
very much resembling tbe chart of septicemia, though the temperature is usually a
little more diumally regular, and rigors are not usually so frequent (compare charts.
Figa. 103, 105. and 14). The diagnosis of these two diseases is Boroetiraes very diffi-
cult (S 50a). Uatignant Endocarditis is favoured by (i.) the existence ot a loud cardiac
murmur detected quite early in the case ; (ii.) a history ot acute rheumatism ; (ilL) the
secondary emboli in this disease are more frequently found in the systemic artariea.

1 88« ] OHRONIC SEPTIC CONDITION 8 629

such as those of the spleen, liver, and kidneys, and they do not result in abscesses.
In pyaBmia the emboli ooour primarily in arteries of the lungs, and from the very
beginning they suppurate and form abscesses, which constitute centres of secondary
infection elsewhere.

Hodgkin'i diiease is recognised by the enlargement of the lymphatic glands. This
enlargement is attended by pyrexia of an intermitting character (§ 408).

In Penucions AnsBmia the temperature is sometimes subnormal, but it is more
frequently attended by exacerbations of fever of an intermitting type. Rigors and
sweats may also occur, but they are not usual. The disease is also identifiod by the
intense sallowness of the skin and the condition of the blood (§ 403).

In Acute Lymphatic Lenknmia the temperature is high and irregular, somewhat
resembling that of septicaemia. It can be diagnosed by the examination of the blood,
when there is found to be an increase in lymphoc3rtes (§ 407).

The Opinm or Morphia Habit is attended irom time to time by attacks of inter-
mittent pyrexia, during the reaction stage, in which there are cold, hot, and sweating
stages. Dr. Livenstein calls attention to this fact, and records cases where no other
cause could be found, and where the attack ceased on giving opium.

Trypanofomiasii (Synonym : Sleeping Sickness) is a disease of Africa, characterised
by enlargement of the glands, often an erythematous rash, irregular pyrexia and exces-
sive sleepiness.

Symptoms. — ^Three stages arc recognised. In the first there is enlargement of the
glands in various situations, especially in he posterior triangle of the neck. In
many cases, especially when the disease affects Europeans, an erythematous rash
is present which becomes ring-, then crescent-shaped. The eruption often coincides
with irregular pyrexial attacks. The second stage may last on and off for two to
three years, with symptoms of hectic fever, increasing lassitude and disinclination to
work, anaemia and wasting. The third or final stage lasts several weeks. There is
increasing lethargy ; the intellect is dull, the face puffy, the gait shuffling ; there are
tremors of the tongue, lips and limbs. The temperature is high at night ; normal in
the morning. Drowsiness increases to profound lethargy, and ends in coma and death.

Etiology. — The disease follows the bite of the Olossina palpalia, and possibly of other
tsetse flies, by which the trypanosomagambiense, Dutton, is introduced into the body
(see Fig. 115). The disease is met with in various parts of Africa, and spreads along
the trade routes.

The Diagnosis can only be made with certainty by finding the parasite in the blood
or cerebro-spinal fluid, or in one of the enlarged glands. The last is the most, and the
first the least, valuable method to adopt.

The Prognosis is very grave. If the patient has not shown any signs of the third
stage, if ho can leave the country and have vigorous treatment, the prognosis is
better than otherwise, but is not good.

Treatment, — The drug of most value is Atoxyl or Soamin ; 2-3 grs. should bo given
intramuscularly every third day for at least two years.

TrichinoBii is often accompanied by intermittent fever.

Bat-Bite fever may show a temperature of an intermittent type.

THE GENERAL TREATMENT OF MIGROBIC DISORDERS,

Remedial treatment has, for the most part, been given under each
disease, but there are some important matters relating to all fevers in
common which must now be referred to — viz., Immunisation, Serum
Therapeutics, Notification and Isolation, Disinfection, Diet, and the treat-
ment of Psrrexia and Hsrperpyrexia. In the first two of these we £nd our-
selves on the threshold of discoveries which are revolutionising the methods
of treatment and prevention of infective disorders.

§386. Immunity. — Before entering on the treatment of microbic dis-
orders by inoculation (serum and vaccine therapeutics) it is desirable to

630 PYREXIA t$3S«

discuss briefly the meaning of the terms " Natural Immunity," " Acquired
Immunity," "Artificial Immunity" (Active and Passive), and "Dual
Immunity." A state of immunity is that in which an individual or an
animal is more or less protected against contracting a certain disease.
There is no such thing as absolute immunity ; it is only a question of
dose of virus as compared with susceptibility. Given a large enough dose
of the virus, even a hen may develop tetanus. Some of the greatest
achievements in preventive and remedial medicine have recently been
reached in this domain. It was a triumph of this kind which Jenner
achieved, though by purely empirical means, in the latter part of the last
century (1796) in the prevention of small-pox by means of vaccination.
After an interval of three-quarters of a century, this important department
of medicine has been enriched by the researches of Pasteur in hydrophobia
and anthrax, Koch in tubercle, Loeffler (1888), Fraenkel (1890), Behring,
Roux, and Kitasato in diphtheria, tetanus, and pneimionia ; Haffkine in
plague and cholera ; Wright in enteric ; and many others too numerous
to mention. Some idea of the latent power for good in these researches
may be grasped when it is remembered that the case-mortality of one
disease alone (diphtheria) has been reduced from over 30 to imder 15 per
cent. According to Loeffler's statistics, the mortality from diphtheria
in the whole of Grermany has been reduced 50 per cent, since the intro-
duction of serum therapy.

a. Natural or Inherent Immunity is that form of immunity which a
human being or other animal possesses at birth (or acquires during its
growth), either by virtue of its species, race, or individual peculiarities.
Thus, difierent animals are susceptible to various infective disorders in
difEerent degrees — hens are practically immune to tetanus, goats, sheep
and rats to tubercle. Certain races appear to become after many genera-
tions relatively immune to some diseases — e.g., measles among Europeans
is now a very mild disease, but when it was accidentally introduced to the
Fiji Islanders it became a devastating plague. Finally, certain individuals
and certain families are more prone to contract infective disorders than
others. I know of one family where three out of six members have had
scarlatina twice, and some of the other infectious fevers more than once.
Different families certainly vary in their susceptibility to infectious
disorders.

b. Acquired Immunity is produced by contracting a disease in the usual
way by infection. It has long been known that one attack of certain of the
infectious disorders confers on the individual immunity from a second
attack. The degree of immunity from second attacks varies considerably
in the different diseases, and roughly one may make three groups, thus :

(a) One attack of the disease confers very strong protection against a
second attack in Varicella, Scarlatina, Small-pox, Syphilis, Pertussis,
Enteric, Dengue, Typhus, Yellow Fever, Mumps, and Whooping Cough.
In the first five of these, and probably in the others also, the immunity
las*;s practically for a lifetime.

§8$6] IMMUNITY 531

(P) One attaok confers only a moderate degree of immunity in Measles,
Pnemnonia, and Diphtheria.

(y) Some confer immunity for only quite a short period — ^namely,
Erysipelas, Cholera, Dysentery, and Influenza. However, it seems
probable that all infective disorders confer upon the individual a certain
amount of immunity — ^for a short time, at any rate.

From these facts the question arises : cannot a mild attack be produced
by inoculation of the infective material from a patient so as to secure
immunity ? And this question was successfully answered in the case of
small-pox, which was so extensively inoculated in the early part of the
nineteenth century, and which was finally forbidden by law after vaccina-
tion became comptdsory.

c. Artifioul Immunity. — Now, what is it that creates this quality
of immunity in an animal or an individual, and can this immunity be
more scientifically produced ? These are questions upon which patho-
logists have speculated for many years, but it was not until bacteriology
had become a science that a solution of them seemed possible. (1) It is now
firmly established that all infective disorders — ^indeed, the great majority
of diseases attended by pyrexia — are due to the presence in the body of
minute living organisms or bacteria, most of which can be cultivated
outside the body. Some of these measure no more than TtFaou i^ch. It
is these minute organisms which constitute the infection. Each disease
has its own particular species of microbe, which has special qualities as
to size, shape, growth, life-history, pabulum, virulence, and so forth,
though some have not yet been recognised. (2) Koch's four criteria, which
identify a particular microbe as the specific cause of a disorder, are so
important that they may be repeated here, (a) The constant presence*
of the microbe in all cases of the disease ; (6) the fact that the microbe can
be cultivated outside the body, the cultures having constant properties ;
(c) the power possessed by these organisms, when inoculated into animals,
to reproduce in them the same disease ; and (d) the same microbe can be
recovered from the local lesion and from the body of the animal after death.

(a) Passive Artificial Immunity, — It is now known that the clinical mani-
festations and lethal effects of these organisms are, in certain cases, due
to the chemical products, the " toxins," evolved by the bacteria, and not
to the bacteria themselves. The toxins and microbes may in these cir-
cumstances be separated from one another by filtration.

The answer to the question, " On what does immunity depend ?" has
been differently answered at different times. At one time it was believed
to depend upon the presence of phagocytes in sufficient abundance to
devour the microbes. Another theory was that an attack of the disease
exhausted the store of pabulum necessary for that particular organism
which was to be found in the blood. Another theory was that the microbes
left behind them something which rendered the soil unsuitable for the
future growth of that particular microbe. None of these were found to
be quite correct. The introduction of a particular kind of microbe or its

632 PYREXIA [§

toxin into the fluids or tissues of an animal sets up a physiological reaction
in the body by means of which a chemical substance (which we call
antitoxin) appears in the blood, which more or less neutralises the toxin
and prevents its lethal action. Antitoxic immunity has, up to the present,
occupied the position of chief interest to the clinician. It must be clearly
imderstood, however, that although antitoxins play the chief part in
immunity against diphtheria, they are by no means so important in
many other infections. In diphtheria, tetanus, dysentery, and botulism
poisoning the antitoxins are of primary significance ; in the great majority
of other bacterial diseases their role is very doubtful. No single theory
can explain the immimity reaction in all cases. The reaction of the body
to the introduction of pathogenic bacteria varies with many circumstances,
and is very different with the various kinds of bacteria. The antibodies
formed may be antitoxins, agglutinins, precipitins, bacteriolysins, opsonins,
bacteriotropins, etc. It is the presence of this antibody, or the faculty
of again producing it on stimulation after the bacteria have disappeared,
which gives to the individual immunity from the infection of that particular
disease. It follows, therefore, that if a particular microbe or its toxin can
be injected into an animal, beginning with small doses, and graduaUy in-
creasing them, the blood serum may be found to contain the antibody
which antagonises the virus of the disease. In the case of diphtheria, for
instance, this has been accomplished by the subcutaneous injection, at
intervals of a few days, into a horse (chosen chiefly because of the large
quantity of serum available) of gradually increasing doses of the virus of
that disease — i.e., the diphtheria microbe grown in bouillon or some other
suitable medium.^ In this way it was found that the animal would
gradually tolerate enormous doses of the virus — doses one-thousandth
part of which would have killed the animal before the immunisation was
commenced. In short, the animal in this way had become highly im-
munised. Next, it was found that if a relatively small quantity of the
serum of such an animal were injected into other experimental animals, it
protected them against many times the lethal dose of the virus. Finally,
it was found that if a small dose — say 10 or 20 c.c. — of the immimised
horse's serum were hypodermically injected into a human being, it ren-
dered him similarly immune to the disease. Moreover, it was found that
if the serum were injected even after the individual had contracted the
disease (if given at a sufficiently early stage), it would cut the disease short,
and prevent the lethal consequences. This kind of artificial immunity —
produced by the injection of serum from an immunised animal — is called
Pensive Immunity.

The explanation of all this is not yet by any means certain, but Ehrlichia
theory is the one now generally believed, and is as follows : The microbic
toodns produce their lethal effects by combining with some constituents of
the cells of the body for which they have a special affinity. But the corre-

^ Some of the methods of introduoing the virus are mentioned below under Active
Immunity,

§S871 IMMUNITY^VACOINE THERAPY 533

sponding antitoxin has a stronger affinity for the toxin than the latter has
for the body cells, and therefore the antitoxin acts by combining with the
toxin, and thus preventing the latter from doing harm.

(fi) Active Artificial Immunity, — We have seen that Passive Immunity
is that kind which is produced by the injection of the serum of an im-
munised animal — it is, as it were, a " borrowed " imnaunity. The term
" Active Immunity " is applied to that kind of exemption which is acquired
by the actual introduction of the microbe or its products into an animal
or person whom it is desired to immunise . In the latter instance the
individual manufactures his own antibody ; in the former he receives the
antibody which has been manufactured in the body of another.

As long ago as 1880 Pasteur began his brilliant series of experiments,
showing that if animals were first inoculated with microbes weakened by
age, heat, or exposure to the atmosphere, and were subsequently inoculated
with the most virulent and actively growing cultures of the same organism,
they had a very mild attack of the disease in question.

The following are some of the methods by which active immunity may
be produced in the laboratory, the chief object being to attenuate the
virus down to a suitable degree.

1. By taking some of a virulent living culture diluted with sterilised
salme solution, and injecting a small non-lethal dose. This is followed by
constitutional symptoms. When these have subsided, a second dose is
injected, and then a third, and so on. The blood normally possesses
a certain amount of anti-bacterial power. It is only when too large a
dose — ^that is to say, too many bacteria — is introduced that it becomes
lethal, and therefore it has been found possible to immunise an animal by
a series of injections of non-lethal doses of the microbe in question.

2. By the injection of a living culture of microbes, the virulence of which
has been attenuated in some way, either by growing it in the presence of a
weak antiseptic, or in the presence of oxygen, or in a current of air. The
virulence of some microbes may also be attenuated by passing them through
one species (a less susceptible species, for instance) of animal, which may
attenuate it for another species ; or, again, by growing the culture at an
abnormal temperature.

3. By the injection of dead microbes (killed by heat, for instance) in
a series of gradually increasing doses.

4. By the use of culture filtrates. Here the bodies of the bacteria are
removed by filtration, and the toxins, which remain in the filtrate, are
injected into the animal.

§ 887. Vaccine Therapy is based on the third principle aboye mentioned. Sir
A. E. Wright and Captain S. R. Douglas have shown by thie following experiment that
the phagooytio power of an individual's blood depends mainly on the serum. The
white corpuscles are first separated from the blood by centrif ugalisation, and are then
washed free of any adherent serum. If these washed leucocjrtes are then mixed with
bacteria and normal saline, and incubated, generally speaking no appreciable amount
of phagocjrtosis occurs ; but if they are mixed with bacteria and serum, and incubated,
phagocytosis results. To tho hypothetical substance in the serum which promotes
the ingestion of the bacteria by the leucocytes they have given the name opsonin.

534 PYREXIA [ § S87

Wright considers that opsonins act by preparing the bacteria for ingestion by the
leucocyte ; for if bacteria be mixed with serum, and the serum be subsequently washed
away, they are then able to be phagoc3rto8ed by washed leucocytes. The opsonic
value of a patient's serum against a particular micro-organism can therefore be
measured by the amount of phagocytosis which occurs when it is mixed and incubated
with washed leucocytes and that micro-organism. To gauge the opsonic value of a
patient's blood, we must compare it with the opsonic value of the blood of a normal
individual as a standard, and the ratio thus obtained is the opsonic index, which
may be stated thus :

^ . . , e ., ...,,, , Phagocyte index of the patient's serum
Opsomc mdex of the patient 8 blood = „t _x • j * i

'^ Phagocyte mdex of normal serum

The result of the study of the opsonic index is that treatment by inoculation of
the dead virus, or vaccine therapy, as it is called, has been greatly extended on scientific
lines, and accurate dosage can now be used at the proper time, whilst formerly the
doses were usually much too great, and often did more harm than good by being
employed at the wrong time. It is claimed to be of value in aiding diagnosis, for it
has been shown that if the index to a particular organism is either persistently low
or high, or if it fluctuates widely, that organism is present in the body.

To estimcAe the opsonic index, the first step is to collect a few minims of the patient's
nerum. This is done by means of a special U -shaped capsule (see Fig. 106). A bandage
is firmly bound round the thumb to produce engorgement, and then a prick is made
on its dorsal aspect just behind the nail-bed. The curved end is now applied to tkud

small pool of blood thus formed, which runs into
the capsule. The bandage may be loosened and
reapplied until sufficient blood is collected to half
fill the capsule. The other end is now sealed in
the flame. As cooling occurs, the blood is drawn
into this end, the .first end is also sealed, and
the sample is ready. The further details are too
Fig. IM. — Wright's Capsule. technical to be described in a clinical textbook,

but the procedure is briefly as follows :
The capsule is allowed to remain until the serum has separated from the clot, and
formed a layer on its surface. The end is then broken off, permitting access to the
serum to be investigated. Two mixtures are made — (i.) of washed corpuscles with
a bacterial emulsion free from clumps in normal saline and the patient's serum ;
(ii.) similar, but with normal serum substituted for that of the patient. Both are
incubated for fifteen minutes. A film is then made of each, and stained, and the
number of bacteria ingested in a hundred corpuscles counted. The opsonic index is
equivalent to the ratio of the number of organisms ingested in the first film to the
number in the second.

The object of " vaccination " is to keep the resistance of the blood at as high a
level as possible. Each injection is usually followed by a temporary lowering of the
opsonic index, and to this period the name ** negative phase " has been given. This
is succeeded by a more permanent increase of the opsonic index, or positive phase.
If a large injection be given during the negative phase, or when the index is very low,
the succeeding negative phase, by bringing the resistance to bacteria still lower, may
do dangerous harm. For this reason it was at first thought essential to know the value
of the opsonic index before each injection, and so regulate the time and dose. Further
experience with this method of treatment has shown that in many conditions it is
unnecessary to determine the index, especially in superficial lesions, where the effect
can be watched. Such, for example, are staphylococcic skin lesions (multiple boils,
acne), conditions which are very successfully treated by vaccine therapy. " Vaccines "
for the treatment of most of the infective diseases of known etiology are now on the
market, and although there are certain cases where an appeal should be made to the
opsonic index, yet in its absence much good may be done by their use. As a rule,
the more ill the patient is. the smaller should be the dose, and, conversely the more
chronic the disonler, the larger should it be. In the treatment of local disease means
must be employed to bring the blood, the immunising power of which has been raised.

§ 888 ] REMEDIAL IMMUNISATION 636

to the seat of disease. This may be done by poultices, fomentations, local depletion,
or the application of salt and sodium citrate. X rays and Bier*s method of passive
congestion act in the same way.

§ 888. Remedial Immnniiatioii. — Gekebal Procedure. — (1) The skin must be
washed, and every possible aseptic precaution adopted. (2) A special syringe is desirable,
though any good thoroughly sterilised syringe may be used in emergency. The best
form is one in which all the parts can be taken to pieces and thoroughly boiled, because
this is the best method of rendering it aseptic (Fig. 107). (3) If more than one dose

Fig. 107.— Aktitoxin Syrinoe.— The chief qualification of an antitoxin Byringe is that it Bhall
be capable of thorough asepsis and that the parts can be separated for that purpose ; the piston
head generally being of asbestos. Another qualification is that it shall be capable of containing
the whole of one dose. The syringe here figured contains 10 c.c. The dose of a bacterial
vaccine is generally much smaller, and an ordinary hypodermic syringe, if capable of being
thoroughly aseptlcised, will do. It is best, if possible, to boil the part«. Failing this, thorough
soaking in strong carbolic solution and afterwards thoroughly washing with sterilised water,
will serve the purpose.

has to be given, it is advisable to made the injection into a different situation each
time. The most usual sites are between the shoulders, the loin or buttock, the front
of the abdomen, or the back of the arm.

Anaphylaxis, or hypersensibility, is the name given to a condition, first described
by Richet, in which an anin-al is unduly sensitive to the action of a foreign albumen.
This hypersensitivenees may te induced as the result of a single injection of the
albumen. For example, if a very minute dose of horse serum is injected into a guinea-
pig, it renders the animal hypersensitive to horge serum, eo that if a subsequent
injection be given, after a certain time, the animal n-ay die immediately with the
most acute symptoms. The hjrpersensitiveness does not appear till after an incuba-
tion period of eight to twelve days. This condition of hypersensitiveness may be seen
after the injection of all sorts of foreign albumens — blood, serum, egg albumen, milk,
etc. It has also been noted after the injection of bacterial extracts, which of course
contain albumen. The practical importance of a knowledge of this condition for the
practitioner arises in connection with the administration of therapeutic sera. If a
second dose be given after the incubation period of the first is over, there is a risk of
anaphylactic symptoms developing. These, however, are rarely severe or dangerous,
especially as therapeutic sera are generally injected subcutaneously, and anaphy-
laotio symptoms are much more liable to follow intravenous injections. On the other
hand, if the second dose of serum is given before the end of the incubation period of
the first, no danger of anaphylaxis need be feared ; during this period one may give
repeated doses of serum without risk of any such symptoms. The symptoms of
anaphylaxis in man are mentioned in § 464. They have been for some time described
as the ** serum disease."

Special Methods for Eacu Disease.

I. DiPHTHEBiA. — An antitoxic serum has been in the market since 1895. When
given early enough and in large enough doses, it has been found to be of the greatest
value as a remedial agent for patients suffering from the disease (see Comparative
Mortality, § 386). It has also been used as a preventive, but it is for this purpose
of only limited value ; it confers immunity for a few weeks only. Some years ago the
Lancet Commission tested several antitoxins in the market, and found many inefficient.
The Con1ra-indicatio7i8 for its use arc given in § .S65,

630 P THE XI A [JISS8

MtOutd. — Tho retnf^y should be oaod m cftrty as possible in the disoMO. A dote of
tX least 4,000 units ' should be given, and ropcatod in holf-doBos ovory twonty-faur
hoars until the exudation is obviously separating. Avoid injecting more than
20 c.c. at one place, if poBsiblo. Tho usual site for injection is subeutaneoualy in the
flanks, but it has lately been shown that valuable time is saved if intratnuscuUr
injections aro usi^. The best site is the intragluteal. It is very important that the
injection nhonld be made oarly ; the earlier tho antitmiit is given, the more favourable
\fi tho prof^osis. Therefore, in suspicious casi>s, where a bacteriological report cannot
bo got at once, the corrcnt treatment is to inject the antitoxin without waitii^ for llic
rcjiort. Children tolerate antitonin well, and nhould receive tho Bnme doe™ as wluiis.
EfffcU, — In the course of twenty-four hours tliere shouhl bo an improvement in
the patient's symptoms : tlie membrane ceases to extend, or perhaps begins to loosen,
the swelling abates, and the rhinorrhcea is diminished. Ocoasional effects are urticarial
or erythematous eruptions, additional rise of temperature, or joint pains and swelling.
II, Tktanus (Pig. lOS).— Of late years the raorlality from tetanus has been
roduced by the use of an antitoxic serum. The tetanus antitoxin wan first prepared
by Bchrini; and Kitasato. There is no superiority in the French antitoxin over tho
German and English.'

Ctmtra-indiealiont.—Tito longer the time that has elapsed between the infection
through a wound and the injection of the serum, tho worse is the prognosis. It is
usually too late to give the serum vhea
tetanic spasms have appeared ; yet caaea are
on record with recovery even after marked
spasms had set in.

Method. — In a decided case of tetanus
100 CO. of the antitoxin should be injected
within twenty-foor hours, at difFereat sites,
in five doses. If there be no improvement
next day, give it again, and continue with
daily injections of about 20 c.c. Koux has
found that tho serum is considerably more
potent by injecting directly into the sub-
dural space after trephining, and advanced
cases have boon saved by this means.'

EffecU. — The patient should sleep well on

the night following the injection, and,

r- ino 1.— .. T. . »„„ '^ fever is present, the temperature should

FlK. 108. — TBTiNPS BiOILLUS. — ) 1.000. ,„ ., ., '. , ,

Cover-glsM preparation, G en tUn violet faU considerably the next day.
Photomlcrognph by Hr. Fiederick Clark. HI- Sbptiojemia and pyscmia (including
Erysipelas, Malignant Endocarditis, and
Puerperal FoverJ. — The pyogenic (pus.pro<lucing) organisms are capable of producing
Bepticiemia — atrc|itoooccus. staphylococcus, B. ooli communis (in aomc ciroumstanoes)
ele. — and the antiserum of one will not act upon another. Antistreptococcic serum
may bo tried if a streptococcic infection is in operation.

Metliod,—AB in all cases treatment should be commenced early, and since the case
may bo ono of mixed infection, some do not consider it desirable to wait for a boc-
leriological report. Start with 20 c.c, and repeat once or twice daily as long as high
fever or rigors continue.

Kfjccts. — In successful oases there should bo an almo.»t immediate fall of tempera-
ture and improvement in tho condition of the patient.

Vacrine Therapy is now employed for septioiemia. A culture is mado from the
patient's blood, and a vaccina prepared from it. Successful caws have. boon report<«d.
In acute cases of malignant endocarditis, puerperal fever, and surgical septioiemia,

* In Behring's serum there are 3,000 units to 6 or 6 c.c. This same serum is now
jirepared at the Lister Institute, and sold through Allen and Hanbary.

" It LB prepared in largo quantities at the Lister Institute, and procurable from Allen
and Hanbury, and elsewhere,

' Method of intracerebral injection is gijon in detail by Dr. Scmple, BriL Mtd.
Jovm., January 7, 1898,

jMS] REMEDIAL IMMUNISATION W

Rive 100 to 200 million organisms; in chronic cases, (five- 200 to 1,000 million. The
dose UBiuilly employed consiBtt of from 1,0(X),000 to 2,000,000 organismg.

IV, Vocaines are now supplied in capsuleB for use in coryza, none, gonooocous, snd
other conditions. In gonorrhoesl rheumatiam good results arc obtained by increasuig
dosea administered every eight or ten days.

V, EsTBRio Fbtkr (Fig. 109).— In 1896 Sir A. E. Wright introduced a method ot
prevetUivt inoculation against typhoid fever.' Agar onlturen of typhoid bacilli are
washed off with aaUne, killed by heating at 60° C, and the number of bacilli estimated.
Two doats are inocutatnl, the first containing 500 million liacilli, the second 1,000
million bacilli, after ten days' intorval. Single doncs are itupplinl in anepticlHrd
" vaccine " tubes, with full diroctionn as to the method of use.

KgecU. — The immediate effectB of a full dose are loss of appetite, faintnoss, nlight
fever, and reetJessnesa, and in twenty-fouf to forty-eight hours the patient is well
again. Locally there may be cedema ; in some oases this is extensive, and Wright has
found that by giving large doses of calcium chloride before the injection the tendency
to local (edema is overcome. The immunity conferred probably lasts a few months ;
the blood scrum may give the Widal reaction for this )>oriod.

Treatment of typhoid fever by a serum has been tried on a larger scale by Chante-
meeae in Paris, and the reaulta reported are excellent — a reduction ot the mortality
from n per cent, to 4-3 per cent. A very small dose (only a few drops) ifl used for
injection, and this may be repeated in ten
days if required.

VI. TuBKRcuL08ia.^|a) Koch first intro-
duced a " tuberculin " made by filtered
baeilluB cultures. This product is now
known as the " old tuberculin;" and is used
solely for diagnostic purposes, for it only
produces a reMtion in an individual when he
has tnberouloBis in some part of his body.
In this country it ia used chiefly for animalB.

MeAod. — Half a milligramme is injected,
and the temperature is taken every four
hours. If during two days there is no rise,
2 milligrammes are given, and the tempera-
ture taken for two days again ; then S milli-
grammes, and the temperature again taken.
If there is no elevation of temperature at
any time the case is not one of tuberoulosia. FiB- lOB.-TTPHoro BACltLus -Cover-^

7a\ V I. _»■ 1 J J 4. I, — 1- preparation showing Bagelto. x about

(S) Koehnextmtroduoedanewtuberculm jo^o. Loeffler's method. Photoralcro-

(T.R.), which consists of finely- powdered graph by Mr. Fraderiek Clark,

bacilli, washed free of toxins.

(7) Lastly, he has introduced a baoiliary emulsion, a suspension of finely-powdered
bacilli in water and glycerine. This is rendered sterile by heating to 80° C, and is
now genef»lly employed. Sir A. E. Wright's researches have shown that far too
largo doses were formerly used. The dosage now ranges from -n^nii milligramme to
"(fcfl miiligramroo, and is controlled by the opsonic index, though in some cases this
may be dispensed with. Dr. Latham has administered tuberculin (T.R.) by the
mouth with either horse serum or normal saline, with encouraging results.

VII. Hydrophobia.— The Pasteur treatment of hydroi>hobia has obtained a
world-wide reputotion. Rabbits arc inoculated with the virus of hydrophobia, and
thoir spinal cords are taken out and dried. The longer these are allowed to dry. the
more attenuated is the virus contained by them. Emulsions are made of the cords,
and these are injected info the patient. Weak cords, which have been dried for
fifteen days, arc first employed, and the virulence of the cord employed is gradually
increased for ten days,

Conira-iBdicoIioBJ. ^Treatment must be commenced as early as possible after the
date of infection. The danger to be avoided in the treatment is ft too rapid increase

in the strength of the virus.

' Wright, the Lwieet, 1886, vol. iL, p. 807, aod Brit. Mtd. Jmm.. 1897, voL i., p. 26*1.

538 PYREXIA [§t89

Method. — The practical points for the practitioner are (i.) to cauterise the wound at
once ; and (ii.) to send the patient to the Pasteur Institution, Paris, taking with him,
packed in ice, the head of the animal which bit him. Thus it can be ascertained
whether the bite was dangerous or not.

The reavlts of this method of treatment are very encouraging. The ordinary
mortality of bitten patients, before the institution of this treatment, was about 16 per
cent., but from 1880 to 1895 (17,337 cases) the mortality was 0*48 per cent. A serum
treatment of hydrophobia is at present on trial.

Vin. Plaoub. — ^The serum treatment of plague is still on trial in India. Yersin's
or Lustig*s serum is employed. It appears to be an antibacterial serum, and is
attended with considerable success. As so few cases can be obtained in time for this
treatment, Haffkine has introduced a method of preventive inoculation by attenuated
cultures, which it is believed confer immunity for about one year.

Contra-indictUums. — ^The treatment must be commenced on the first day of the
illness, because the course of the disease is bo rapid and severe that later administra-
tion cannot check its progress.

Method. — From 20 to 40 c.o. are injected daily for one to ten days, aocoiding to
the nature of the case.

Effects. — Cases have recovered in two days when the treatment was commenced on
the first day of illness. In such cases the mortality has been greatly reduced.

IX. Choleba. — A cholera antitoxin has been introduced, but is still on trial.
HafFkine has been able to confer immunity for a year by inoculating two or three
times with attenuated cholera cultures, then with more exalted virus. The results
were encouraging : fewer people were attacked ; but those who were attacked did not
have a modified or milder form of the disease. Hence he has more recently attempted
to produce an inoculating material which shall contain antitoxic properties as well
as antibacterial.

X. Snake Poison. — Calmette introduced an antitoxic serum for the poison of
snake bite, which is known as " antivenene." It is e£feotive against the venom of
the colubrine snakes, but often fails to neutralise that of the viperine species. The
serum can be kept for a long period in a tropical climate without losing ita properties.

Method. — Inject as soon as possible after the bite at least 10 c.c. of Calmette^s
antivenene, and repeat the dose some hours later.^

Effects. — The patient recovers veiy soon if the injection is given before unconscious-
ness or paralysis set in. Even if given when respiratory paralysis threatens, this
dangerous symptom may not ensue, and the paralysis of the limbs usually disappears
in less than two days.

XI. Pneumonia. — ^The serum treatment of pneumonia has as yet been tried chiefly
on animals. In animals remarkable results have been obtained. Thus 1 c.o. of Pane's
serum protected a rabbit against 3,000 lethal doses of a living culture of the pneumo-
coccus. Good results were expected from this method of treatment in the human
being, but it has proved disappointing. The serum of a patient who has recovered
from pneumonia protects, to some extent, rabbits from the pneumocooous. This
serum is probably antibacterial. Vaccines are beginning to be employed, in some
cases with marked success (see § 87, Treatment of Pneumonia).

XII. Anthbax. — Animals have been inoculated with increasingly virulent doses
of anthrax cultures, and the results are encouraging as a preventive. Sclavo's anti-
anthrax serum has given good results in man. Inject 30 to 40 c.c. subcutancously
distributed in several situations, and lepeat in twenty-four hours. In severe cases,
inject 10 c.c. intravenously.

Xm. Cebebro-Sfinal Fevbb. Flexner has introduced an antibacterial serum.
This is injected into the spinal canal on several successive days in doses of 15 to 30 c.c.
The results are excellent. It should be used in all cases of this disease.

XIV. An antitoxin is employed in dysenteby of the Shiga-Kruse variety 20 c.c;
doses of the serum are supplied, and should be administered early. In severe cases
double that dose may be given.

§ S89. Voiifloatioii and IioUtion. — Two duties are laid upon the medical practi-
tioner in cases of the commoner infectious maladies : (1) Notification of the case to

^ Cases narrated in Brit. Med, Jourv., 1899, vol. ii., pp. 143, 1732, and elsewhere

§ 890 ] NOTIFIOATION AND ISOLATION 689

the medical officer of health of the district in which the case arises. The notifiable
complaints in most districts are scarlatina, diphtheria, ** membranous croup," polio-
myelitis, enteric fever, and " continued ** fever, small-pox, cholera, erysipelas, typhus,
rdapsing fever, phthisis, puerperal fever, and plague (measles and varicella are volun-
tarily notifiable and the public ambulances may be used for them). A medical man is
bound, imder a penalty of forty shillings, to notify any of the maladies named " imme-
diately on becoming aware '* of its existence. (2) Removal of the patient to a fever
hospital is oompulsoiy, unless the parents or guardians can make proper and adequate
arrangements for the isolation of the case at home. In some places the removal is
superintended by the medical officer of health. In the metropolitan area the medical
practitioner should at once communicate with the central office of the Metropolitan
Asylums Board, Victoria Embankment, E.G., when an ambulance will promptly be
sent for the case. Their telegraphic address is *' Asylums Board, London,'* and the
particulars required to be sent are Name, Address, Disease, Age and Sex of patient,
and Severity of case.

It is far better for the patient and for his relations that he should be removed to a
properly organised Fever Hospital ; but to isolate a patient at home, hang a sheet,
constantly wet with carbolic solution (1 in 20), across the door or passage. Carpets,
curtains, and superfluous furniture should have been previously removed. Books
and articles in use must be such as can be afterwards burned. Ventilation must be
carried out as described below. The nurse in charge of an infectious case should
wear a washable dress when on duty, and should hold no communication with others,
nor should she go out of doors without having first changed her wearing apparel, and,
if possible, taken a bath. An airy, quiet room at the top of the house having cubic space
of about 12 X 12 X 10 feet, is desirable. The air in this space requires to be changed
three or four times in every hour. Only the furniture in immediate use should be
allowed to remain. The carpet should be taken up, and all stuffed furniture removed.
The bedstead should be so placed as to be accessible on both sides. The temperature,
read on a thermometer suspended near the bed, and away from draughts, should be
60° F.

Ventilation must be ample in fever cases, because of the danger of mixed infec-
tions. There are reasons for believing that the tonsils are sometimes the portal for
infection, and that, perhaps, is the reason why mixed infections are more apt to arise
in oases of scarlatina when there is not free ventilation and sufficient cubic space.
This partly explains the higher death-rate from infectious diseases when overcrowding
occuired in former days. The direction of the wind should be constantly noted, and.
to avoid draught, the windows or ventilators opened on the side of the room away from
the wind. A " sash-board *' is an excellent contrivance for avoiding draught. It
should be about 6 to 8 inches broad, and fit across the bottom of the window, so that
the lower sash can be raised without a visible opening, and then ventilation takes
place behind the sash-board, and also in the middle of the window, the air in both cases
being directed upwards. The chief principle involved in all ventUation is that the
current of air always takes place from a colder to a hotter medium — ^usually, therefore,
from outside to the inside of a room. The chimney, when the fire is alight, is the only
reliable exiU Make the window your inlet in preference to the door.

§890. Difinfeotton and Prevention. — Before describing the means employed for
disinfeotion, it is necessary briefly to describe the way in which microbic disorders
are propagated. Since bacteriology has become a science, great advance has been
made in this direction. There are three principal ways by which infection is con-
veyed— by the air, by water or other ingesta, and by direct contact or inoculation —
and microbic diseases may be thus classified.

(a) As regards the air-home group, there is considerable variation in their infec-
tivi^, also the distance to which die contagion in an active state may be carried
through the air. For instance, eiysipelas and typhus probably do not spread beyond
a few feet, but small-pox and scarlatina may spread for many yards, some say the
former spreads to a distance of a mile or more.^ Air-borne diseases can also be con-
veyed by furniture and other articles in common use. The portal by which most of

^ Some valuable data on this question were collected by the author from the War-
rington Small-pox epidemic, 1901-1902. — Appendix to the Report of the Roy. Com. on
Vaccination.

640 PYREXIA [|

these diseases enter the system is generally believed to be the lungs, but certain facts
lately observed point to the tonsils, throat, and nose as possible channels for their
introduction. Some of this group may be conveyed by mUk, and it is possible that
other ingesta may become contaminated by the contagia of these diseases. The air-
borne diseases are as follows : Varicella, Scarlet Fever, Small-pox, Measles, Rubeola,
Diphtheria, Erysipelas, sometimes Influenza, Mumps, Rheumatic Fever, and
Whooping Cough. Pulmonary Tuberculosis usually arises from the inhalation of
contaminated particles.

(6) The waAer-home group only comprises three diseases — viz.. Enteric fever.
Cholera, Dysentery. Two facts form the basis of the propagation and prevention of
these diseases : (1) All matters coming from the patient's bowels and stomach arf
infective, in enteric the urine also ; and (2) to produce the disease the virus must be
introduced by the mouth into the alimentary canal.

(r) The third group comprises disorders the infection of which must be introduced
into the blood or tissues of the body in order to produce the disease, either by means
of a wound or a scratch which may perhaps have escaped notice. Our profession
pays a penalty every year to this group of disorders when, perhaps, some overworked
practitioner is called to the bedside of a syphilitic lying-in woman, and forgets to
examine the margins of his finger-nails, where some crack or unsuspected scratch will
be the means of the introduction of the syphilitic poison. Some of these disorders
were formerly described as miasmatic — i.e., dependent upon some meteorological,
telluric, or climatic influence, which we did not understand. Malaria is an example
of these diseases, but it is now known to be directly introduced into the blood of the
patient by the bite of a mosquito. Tdanus and Plague are other examples ; tetanus
is introduced through a wound or scratch which has become contaminated with the
soil ; plague is conveyed by rat fleas. Septicamiia is due to the internal or external
contamination of the blood-current, and all kinds of dust probably contain pyogenic —
i.e., septicaemic — microbes. Glanders is contracted from horses by the contamination
of a wound or scratch ; and Anthrax is contracted by woolsorters and others who come
in contact with the hides of animals containing the contagion, and thus inoculate a
scratch or inhale the dust. Tuberculosis is placed under this group because it is some-
times undoubtedly inoculated into a wound, giving rise to lupus vulgaris or verruca
necrogenica on the hand. Hydrophobia must be inoculated, generally by the bite of
an animal suffering from rabies. Gonorrhoea is conveyed either to the urethra or
conjunctiva, but whether a breach of surface is necessary or not is not known.

It follows, therefore, that the prooediire for disinfection differs somewhat in the cxse
of air-borne diseases, water-borne diseases, and those introduced by the contamination
of a wound or scratch.

1. For Ant-BORNB Diseases —

(i.) The linen, before washing, should be left to soak in carbolic solution (I in 80).
In any case, rather than leave clothes and linen exposed to the air, keep under water
until they can be removed (a wineglass of carbolic acid to a gallon of water is roughly
1 in 80).

(ii.) Clothes and Bedding. — If a disinfecting oven (at a temperature of not less than
210® F. or more than 320** F.) or a steam-heated chamber at 212° F. is not available,
they may be spread out in the room, and treated by sulphur (see below) or formalin
spray. It is very doubtful if the fumigation of clothes by sulphur is of much
use. Washable articles should he plunged into a tub coTitaining carbolic solution
(1 in 80, vide supra), and then sent to the wash, when they should be boiled.

(iii.) The patieifvt, before returning to his friends, must have several warm baths, and
be washed with carbolic soap. This is very necessary in diseases where desquamation
occurs, and anointing with carbolised oil is recommended.

(iv.) To Disinfect the Room. — Close the windows and doors, and stop up all crevices.
Melt some sulphur over a fire in a saucepan or small iron bucket, set it alight, and place
it on an old tray in the middle of a room ; then shut up the room for twenty-four hours.
Use IJ pounds of sulphur for every 1,000 cubic feet — 3 pounds for an ordinary sized
room. The fumes are very suffocating, but they will not hurt anything if the air be
dry, excepting brass, and this may be protected by smearing it over with vaseline.
A whole house may be fumigated in this way from the basement by closing the

K891.89S] DISINFECTION AND PREVENTION 641

windows, stopping up the chimneys with newspapers, and opening the doors of com-
munication. Nowadays it is recognised that a gaseous is much less thorough than a
fluid disinfectant, and the walls should be washed with perchloride of mercury or
saturated with formalin sprays. Formalin may be used as a vapour in the same way
as sulphur. It is conveniently supplied as candles, which may be burnt.

2. For Wateb-bornb Disbases —

(i.) The excreta, if practicable, should be burned ; if not, before being removed
they should be covered with chlorinated lime or carbolic solution (1 in 40, vide, supra).

(ii.) The underlinen, towels, bedding, etc., must be boiled, or treated very carefully
as in air- borne diseases.

(iii.) All drinking-uxiter should be boiled if there is the slightest suspicion of its
being contaminated by leakage, soakage (however small) from cesspools, drains, or
the reckless casting of slops, etc.

Idflt of common disinfectants : Extreme heat (200° F. or more, and preferably
moist) ; fumes of burning sulphur (SO2) ; chlorinated lime ; chlorine, evolved from
chlorinated lime by hydrochloric acid (spirits of salts) ; carbolic acid (a wineglass of
carbolic acid to each gallon of boiling water is roughly I in 80 solution) ; formio
aldehyde ; permanganate of potash (Condy^s fluid) ; chinosol ; lysol ; sulphate of iron ;
sulphate of copper ; creolin ; corrosive sublimate ; terebene ; thymol ; eucalyptol ; sanitas.

3. Disinfection and the fbevemtion of diseases included in cub third group
differs in each individual case. Thus septicaemia and tetanus almost ceased in surgical
oases with the introduction of cleanliness and asepsis. Various tropical fevers are con-
veyed to man by the bites of mosquitoes, flies, fleas, and bugs. The prophylaxis of these
conditions includes mesksurcS directed to the extermination of the insect responsible
and avoidance of plsices in which they are known to bo present. Thus in malarious
districts mosquito nets and tents are necessary, and the pools or other stagnant water
in which the larvse of the Anopheles or other incriminated species live should be
treated with kerosene. In places where plague is endemic the rats should be destroyed ;
where bugs infected with disease are found it may be necessary to adopt such measures
as burning the huts, etc., in which the eggs are likely to have bc<;n deposited. Many
of these insect pests cannot be satisfactorily dealt with by any means at present
discovered, as full knowledge of their life-history is the necessary preliminary to
effective steps for their destruction.

§ 891. Diet in fevers is a question of great importance. It should consist mainly of
milk and meat juices. No more than 3^ pints of milk per diem should bo given,
fresh — sterilised if possible — or scalded (not boiled), in small quantities at a time ;
and it may often with advantage be diluted with half or a third of water, soda-water,
or barley-water. If curds arc passed, the milk may be peptonised, or sodium citrate
may be added in the proportion of 2 grains to the ounce of milk. Lime-water may be
used instead if diarrhoea be present. If milk is not well tolerated, whey or cream may
be given, or the yolks of eggs or egg-flip. Beef-tea, chicken or mutton broth, about a
pint in the twenty-four hours, should also be given, and may be supplemented by some
of the many modem substitutes {e.g., Liebig's or Valentine's extract, Bovril, etc.).
Where the intestinal canal is much affected meat extracts and jellies should not be
given. Some methods of preparing invalid foods are given in § 212. Iced water is
vary agreeable, but it generally increases the thirst. Fresh lemonade may be advan-
tageously substituted by mixing a drachm or two of bi-tartrate of potash, with a
little sugar, to the pint of water.
§ 892. The Treatment of pyrexia and hjrperpyrexia comprises six indications :
I. HecU production can be diminished and heat loss increased to some extent by means
of drugs, known as antipyretics such as antifebrine, antipyrine, and phenacetin.
The first of those is, on the whole, most efficacious for reducing temperature, but it
requires care, on account of its depressing effect on the heart, and the reaction which
follows some hours later. Quinine in full doses (say 5 grains every three or four hours),
may be given until the temperature comes down or physiological symptoms are pro-
duced (singing in the ears, deafness, headache, etc.). Salicylates, especially in rheu-
matic affections, and aconite are also useful. Among the more familiar but less effi-
cacious febrifuges and diaphoretics are liquor ammonice acetatis, potassium nitrate,
Bpiritus setheris nitrosi, and camphor; also lemon drinks, dilute acids, and salines.

642 PYREXIA [S8M

Kairin is said to reduce febrile temperature very rapidly, but is apt to produce profuse
sweating (which may, however, be combated by atropine), or shivering (which may
be combated by quinine), or collapse, if the dose be too large. Parthenine (an alkaloid
derived from Parthenum histerophus (LinnsBus), has been known as a febrifuge for a
long while to the country people of Havana, where its common name is Escoba Amarga.
Febrifuge doses of 2 grammes may be given. It was tried with success in eighty
patients by Dr. Ramirez Tovar.

2. To aid the loss of heat is a method of treatment called for in cases of hypeipyrexiA
{i.e., when the temperature reaches above 104*5^ F.), by means of the graduated bath,
the wet pack, sponging, the application of ice-bags, or Leiter's Coil.

The Oraduated Bath, — Place the patient in a bath one-third full of water at 90*^ or
05° F. Every five minutes reduce the temperature 5° until 60** F. is reached. If the
patient's fever be not then reduced to 100° F. or lower, he may be left in a further
quarter of an hour if his pulse be a fair strength. The pulse must be closely watched,
and alcohol given if necessary.

The Wet Pack, — ^Take off the nightshirt and superfluous bed-clothes, and place the
patient oh a blanket. Moderately wring a sheet out of ice-cold water and lay it along
his side. Gently roll him over on to it, and completely envelop him in it, head and
all, except the face, so that it is next his skin, without creaises or air, between the
legs and beneath the arms. Cover these latter with wet towels. Then put two
cradles over the patient, and blankets over all. Leave him thus packed for twenty to
forty minutes, imtil his temperature, taken in the mouth, is reduced to the required
extent.

Tepid Sponging, — Lay the patient in a blanket and sponge him gradually all over
with tepid water (about 75°). Do half the body at a time, the other half being covered
up. Continue the process for twenty to forty minutes, until the fever is reduced.

The application of ice in large ice-bags for the head, chest, and abdomen has been
used when other means are not available, but the weight of the bags and their localised
application are objections to their use. Leiter's Coil consists of a specially made coil
of metal or rubber tubing through which cold water is continually running. This coil
may be applied to the head, abdomen, or chest. Neither of these two last methods
are recommended for fever cases.

3. To diminish the work done by the internal organs is another means of combating
pyrexia. This may be done by diet [vide supra), and by promoting the action of
the skin and bowels, in order to relieve the kidne3rs Salino purges fulfil the latter
indication (F. 46, 51, 55, and 63, are useful).

4. In all fevers it is necessary to watch the heart very carefully, and, if necessary,
to steady it by means of strychnine and digitalis, or to aid its flagging power by means
of stimulants. The pulse should be examined several times a day in all fever cases,
if only for this purpose.

5. Symptomatic treatment may also be necessary, but this has been dealt with in the
preceding pages. The constipation must be relieved by calomel or saline purges, the
thirst by lemon water in sips (not ice), and the headache by phonacetin.

G. The last indication is to waichfor and treat complications as they arise. The chief
of these are (i.) cardiac {vide supra), and (ii.) delirium and insomnia. If the delirium
be of the raving kind, chloral and bromides should be given in full doses ; if, on the
other hand, it be of the muttering or typhoid variety, stimulants and ammonia are
indicated. Insomnia may be relieved by the same treatment, and alcohol may be
useful in this respect, (iii.) Pulmonary complications, (iv.) suppression or retention of
urine, and (v.) collapse, are all dealt with elsewhere.

CHAPTER XVI

GENERAIi DEBILITY, PALLOR, EMACIATION

A PEBLiNO of general weakness and lassitude is a symptom common to a
great many diseases, but wo are now concerned with those in which this
is the only obvious, or at least the most prominent, symptom for which
the patient seeks relief. Diseases in which debility is the chief symptom
may be classified clinically into two great groups according to whether
they come on acutely and are attended by pyrexia or not. Debility
coming on acutely and attended by pyrexia was fully dealt with in the
preceding chapter. There still remains a large group of diseases in which
the wealmess is of gradual onset, nms a chronic and indefinite course, and
is unattended for the most part by any notable elevation of temperature ;
and these diseases may be attended by pallor or by emaciation. Here
we shall often' meet with the beginnings of disease, beginnings which may,
however, lead to a serious and fatal issue. It is, therefore, of the highest
importance that an exact diagnosis should be made, and treatment
adopted as early as possible.

The debilitating conditions mentioned in this chapter may be un-
attended by any other symptom, or only by the pallor of anaemia or the
wasting of malnutrition, and many give rise to no characteristic ana-
tomical changes after death. Their pathology in some instances is ex-
tremely obscure, and its elucidation in the future must largely depend
upon the co-operation of the analytical chemist with the physiologist and
the physician, a large proportion of them being imdoubtedly due either to
some kind of autotoxic, haemolytic, haemogenitic, or other blood changes
on the one hand, or to malnutrition and a profound disturbance of
metabolism on the other.

PART A, SYMPTOMATOLOGY.

§ 888. General Debility. — Malaise, lassitude, inability to complete a

day's work, are some of the terms used to describe the symptom under

consideration, which is essentially chronic in its course. The weakness

is generalised, and it may affect the mind as well as the body, for there

is not only a disinclination to take muscular exercise, but an inability

to concentrate the attention or accomplish mental work. The weakness

543

644 GENERAL DEBILITY, PALLOR, EMACIATION [ SS9S

may vary in kind and degree from very slight malaise to a total incapacity
to move. Many diseases in this category are apt to be overlooked in their
earlier and more curable phases. The patient may attribute his ailment
to " slight digestive derangement," or think he has " been working too
hard," or " wants a change," and perhaps he calls on his doctor " as he
was passing " just to confirm his own diagnosis and *' give him a tonic."
These cases may tax the young practitioner's skill and tact in several way«.
Fresh from studying instances of marked diseases in hospitals, he may
regard these cases as trivial and '^ uninteresting " ; and even if he detects
the beginning of some insidious malady the patient may meet his sugges-
tion of serious ailment not only with surprise, but even with resentment
and distrust. Some tact, therefore, is required, and the practitioner may
find it wise to place himself in communication with some discreet friend
or relative of the patient.

Fallacies, — The distinction of general debility from paralysis is not
usually difficult, though patients with multiple peripheral neuritis, early
paraplegia, general paralysis of the insane, bulbar paralysis, and various
other forms of paresis, often come to my clinique complaining simply of
weakness. Cases of malingering offer far greater difficulty in diagnosis
from general debility, for in both cases we are almost entirely dependent
upon the patient's own statements. The question of motive should be
considered and an exhaustive examination made by the most up-to-date
scientific apparatus, but even then we may in justice be compelled to give
the patient the benefit of the doubt. My experience at the Paddington
Infirmary taught me in many cases that it is only by keeping the patient
under daily observation, and with the aid of inteUigent, experienced, and
well-trained nurses, that a correct conclusion can be gained. I have no
doubt that large numbers of able-bodied malingerers gain admission to the
infirmaries in Great Britain as cases of general debility. Hysteria and
f^eurasihenia may require to be distinguished from debility. The Causes
of debility are discussed in §§ 401 and 418.

Pallor of the Skin — i.e., deficiency of its normal colour — is a frequent
accompaniment of cases in which debility is complained of by the patient,
and the experienced observer can detect considerable variations in the
different varieties of pallor belonging to several diseases which will be
alluded to shortly (§ 401 et seq.).

Fallacies. — Slight jaundice may resemble some forms of pallor. In
town-dwellers who suffer from a deficiency both of fresh air and sunlight,
pallor of the face is common. In certain " delicate " families a pale face
is more or less normal. Europeans who have lived long in the tropics are
habitually pale and " anaemic " looking, but the blood may not reveal
any changes of anaemia. On the other hand, patients may occasionally
present flushing of the face and redness of the lips, though undoubtedly
suffering from anaemia. In certain nervous conditions transient con-
striction of the vessels may cause a pallor which may be mistaken for
anaemia.

^ 894 ] PH Y8IGAL EX A MI NATION 546

Emadation, or loss of flesh, may also be associated with general debility,
and its presence adds considerably to the gravity of a case, for it indicates
either serious organic disease such as cancer or tubercle, or definite defect
in the alimentation or metabolism of the body, such as is produced by
intestinal trouble or chronic Bright's disease. It is manifested to the
patient by his clothes becoming looser, or his face becoming thinner, and
to the phyBician by pinching up a fold of skin between the finger and
thumb. But the only reliable test is a definite loss of weight, and it is
advisable at the outset to ascertain and record the weight of all patients
who come to us complaining of debility. To ascertain the net weight,
one-twentieth of the gross weight may be deducted for summer, and about
one-eighteenth for winter, clothes. Every consulting-room should be pro-
vided with scales. The causes of emaciation are discussed in § 415 e^ seq.

Fallacies. — A normal loss of adipose tissue may occur about the climac-
teric, but the reverse is quite as usual. In advancing years loss of flesh,
or the reverse, is normal in some families ; both are largely a question of
heredity. Amyotrophy, imless generalised, is not apt to be confused witli
emaciation ; it is usually localised. The diet a person has been taking
will, within certain limits, influence his weight considerably, and one who
has been taking only nitrogenous food (e,g,y the so-called Salisbury diet)
may be many pounds under his normal weight.

PART B. PHYSICAL EXAMINATION.

§ 884. The physical examination of cases of general debility, pallor, or
emaciation, comprise (1) Examination op the Viscjera; (2) Observa-
tions ON THE Weight, and in some cases on the Temperature ; and
(3) An Examination op the Blood.

1. An examination of the Viscera should be very systematically and
thoroughly conducted (see Scheme, pp. 6 and 7), because we may be
dealing with some incipient disease, the signs of which are obscure. In-
quiries should be specially directed to the state of the digestive organs,
and the urine should be carefully examined. Special importance will
attach to the latter when we know more about the causes and consequences
of abnormal hsBmolysis (blood destruction).

2. The Weight of the patient should be noted, and, if possible, com-
pared with previous records. It may be desirable also to take the patient's
Temperature if any pyrexia be suspected, and to obtain a series of
records (§ 347).

3. An examination of the Blood is necessary, especially in cases where
any form of anaemia is suspected. This in its complete form consists of
(1) estimation of haemoglobin ; (2) blood-counts of the red and white
corpuscles; (3) examination of blood-films. In most cases these three
wUl be sufficient for a routine examination ; but in other cases it is neces-
sary to make (4) an examination for parasites and other abnormal con-
stituents ; and (5) certain physical and chemical properties of the blood.

546 OENERAL DEBILITY. PALLOR, EMACIATION [§§S96, 896

Examination op the Blood.

I 895. Apparahii and Meihodi — ^Apparatus Bequibbd. — A Tallqvist hsemoglobin
scale or Gowers* hsemoglobinometer ; a Thoma-Zeiss hsemooytometer ; a sharp needle
(the triangular surgical needles are very useful) ; a bottle of Hayem's solution ; a
bottle of Toison*s fluid ; a bottle of Wright's modification o }Leishman*8 stain ; a
bottle of distilled water ; a bottle of alcohol ; a bottle of ether ; some squares of butter-
muslin for cleaning lenses, etc. ; white filter-paper (blotting-paper) ; a case for holding
slides ; slides and cover-slips ; a pair of rubber bellows for drying pipettes ; and a bulb
and stem for cleaning pipettes.^ Cover-glasses and slides must be peifeotly clean and
free from greasiness. Cover-glasses should never be laid flat on the table, but have
one edge on the table, the other edge leaning on some object.

For the estimatum of hcsmoglobin the following apparatus are in use : the Tallqvist
scale, Gowers' haemoglobinometer, Von Fleischl's hsemometor, and Haldane's and
Oliver's hsemoglobinometers ; Gowers' instrument is the one most used. For oourUing
the blood-cells the Thoma-SSriss haemooytometer is employed. Diluting solutions are
required for this purpose. For counting the 'red cells a solution of normal saline may
bo used, or Hayem's solution ; sod. chloride 1 grm., sod. sulphate 6 grms., hydrarg.
porchlor. 0-6 grm., aq. dest., ad 200 c.c. For counting the white cells a 0*3 per cent,
solution of acetic acid coloured by methylene blue is used, or Toison's fluid (methyl
violet, 0*025 grm. ; neutral glycerine, 30*0 c.c. ; distilled water, 80*0 c.c. Add to this
a solution of sodium chloride 1*0 grm., sodium sulphate 8*0 grm., distilled water
80*0 c.c, and filter). The instruments must be carefully cleaned before being put
away, first with water, then with alcohol and with ether, and then dried.

Method of Obtainino Blood. — Certain precautions are necessary to obtain satis-
factory results in procuring a specimen of blood for examination. A series of obser-
vations on the same patient should be carried out as far as possible always under the
same conditions, because there are physiological alterations in the constituenta of the
blood after meals, cold baths, and exercise. The necessary blood is to be obtained by
puncturing the lobe of the ear with a surgical needle, a lancet such as is supplied with
most hsemoglobinometers, or a steel pen of which one half the point has been broken
off. The ear should not be first cleaned, as this is unnecessary, and alters the compo-
sition of the blood locally. The puncturing instrument must, however, be sterilised
by heat or by keeping it in a small tube of alcohol. A sufficiently deep puncture
should be made to obviate the necessity of squeezing the ear to procure enough blood.
If it is only desired to take blood for the purpose of serum reactions, squeezing the
ear is of no moment, but if for study of the colls it must be avoided. The practico
of obtaining blood from the finger is unpleasant for the patient and inaoonrate.

§ 896. Ettimation of the Hamoglobin. — In estimating the quality of the blood the
number of red cells is of less importance than the amount of hsemoglobin, their active
constituent. Haemoglobin may be roughly estimated by the TaUgvist ecale,^ which
consists of a lithographed scale of tints. A drop of blood is sucked up by one of the
pieces of blotting-paper supplied, and compared with the scale of tints as soon as the
stain has lost its humid gloss. The figures beside the tints represent the percentage
of hsemoglobin present, normal being 100. The estimation can only be performed in
full daylight.

Another method of estimating the hsemoglobin is by means of Ootvers* hcemoglQ'
hinomeUr (sec Fig. 1 10). Place a few drops of distilled water in the graduated tube ;
with the pipette suck up 20 cmm. of blood, and blow this into the tube, mixing to
prevent coagulation. To ensure the removal of all the blood from the pipette refill
it with water several times, and blow into the tube. Hold the tubes together against
the light or a sheet of paper, and add water from the dropping- bottle until the colours
of both tubes correspond. Good daylight is required for this test. Note the number
at the surface-level of the mixture. This gives the percentage of hsemoglobin in the

^ Baker of Holbom supplies these in a case to the specification of Dr. Gordon
R. Ward.

^ The Tallqvist scale can be obtained from Messrs. Allen and Hanbury, Wigmore
Street, London, tJie authorised agents for England.

51971 ESTIMATION OF THE HEMOGLOBIN W7

eiamined blood compared to the normal. When the blood is vary poor in htemo-
globin, it is well to Gil tho pipette twice or even three times, subaequentlj dividing the
pcroentage accordinglj. The amount of hiemoglobin may also be eetimatod bf
Haldano's htemoglobiuomet«r. Von Fleiachl's hamomoter, or by Oliver'i heemogbbino-

Signifijianet of DiminMlion or Incrttut of Hamoghbin. — The amount of htemoglobiu
ia always ezproaead in terms of a pensentage of the normal standard. Thus, S7 on
the Bdale indicates that the amount is S7 as compared with the normal of 100. A
diminution of hemoglobin is the essential feature of all aniemiae, but the variona
forms of aniemia diSor as regards the number of blood-cells. The htemogtobin may
be rapidly estimated in tho consul tiug.Toom by the Tallqvist scale ; it is useful, for
example, to gauge the degree of progroaa a patient is making under treatment for
aanmia. In chlorosid there is a marked diminution of hnmoglobin in each corpuscle,
tbougb their number may not be much diminished. On the other hand, in pernicious
anemia the diminution of hiemogbbin is due to the diminution in the number of red
oella. each of which oontaiua the normal or above the normal htemoglobiu value. Tba

Fig. 110. — Oowms' HmoaLOriBOJlBlBE.— A, Pipetta dropping- bottle with rubber lop ; U, ■
capillary pipette marked at ZD cmm. ; C, sd opsd tube ol the ume ilia u D, gradUAted ao
that 100 degree* equals 20 rnim. of blood diluted 100 timet ] D. a ciOMd tube wltta a lolutlon
ot ptcrC'Carmiae Hlycerine, the colour c[ which carrespoods to that ot normal blood diluted
100 timet ; F. a guarded lancet.

amount of hiemogbbia in each corpuscle is expressed by making a fraotion, the
numerator of which is the porcentage of hiemoglobin present (as estimated by the
hiemogtobinometer) and tho denominator of which is the percentage of corpuscles (as
estimated by the hsmocytometor). For example, if thi^ examined blood has 40 per
cent, hsemogbbin and SO per cunt, red corpuscles, tho value of hemoglobin in each
oorpusale is i'^iha normal. This fraction expresses the colour indtx of the blood, or
ratio between the percentage of hsemoglobin and the percentage of red corpuscles.
If the colour index is much bebw unity, the aniemia present is of a ohbrotic type,
luid in most cases the prognosis is good. On tho other hand, if the colour index is
1-2 or higher, the probability that pernicious anaemia is present is strengthened. In
dealing with cases of cyanodis the amount of hiemoglobin may enable the physician to
decide whether the case is one of true polycythiemia or one dependent upon dnig-
toking. In the latter the hiemoglobin is rar.'ly ineraasod ; in true polycythemia it
usnally is so. In town-dwellers tho hemoglobin is usually only 80 to 90 per cent. ;
in out of door workers it may be over 100 per cent.

§ SS7. Blood Connti. — An estimation of the number of corpusclee in the blood ja
n many cases of extreme importance both for the diagnosis and Iha treatment of

548

GENERAL DEBILITY. PALLOR, EMACIATION

[§S»7

disease. Two instruments are in use for this purpose, the Thoma-Zeiss and Gowere*
hsBmooytometers. The former is more convenient, requiring a smaller quantity of
blood, and having a smaller percentage of error. We shall consider first the metiiod
of estimation of the i^umbeb of bed cells in a cubic millimetre of blood, by means of
the Thoma-Zeiss hcBmocyiometer. The apparatus consists of a mixing pipette B, a
graduated counting slide A (Fig. Ill), and a diluting fluid (§ 395). B.foro starting
see that all the instruments are clean and at hand. Suck up the blood from the drop
to mark 0*5 into the capillary pipette ; if any of the blood reach the mixing chamber E
the instrument must be cleansed, and the process started again, as it is necessary to
be very precise in this measurement Wipe rapidly the end of the pipette, plunge it
into the diluting fluid, and suck it up to the mark 101. To enumbratb the lbuoo-
OYTES a special pipette, marked 11 above the bulb, is supplied. It gives a dilution of
1 in 20 if the blood is sucked up to mark 0*5. The diluting fluid is drawn up to the
mark 11. Holding the pipotte betwcon the finger and thumb, rotate and shake it
BO as to thoroughly mix the fluids in the mixing chamber ; the glass ball in E groatly
facilitates this process. [If the blood is collected at the bedside, it is necessary to carry
it elsewhere before the counting can be done. To ensure its safe conveyance, remove
the mouthpiece from the rubber on the end of the pipette, and turn the end of the
rubber over the end of the pipette. They must be carried horizontally, or the result
will be valueless.] Next blow out and discard the clear fluid from the capillary end
of the tube, and also three or four drops of diluted blood ; then let a fraction of a drop

3>>

^ .»;;-.*■'.

C^anr^B

Fig. 111.— The Thoma-Zeiss Hjbmooytometer.

fall upon the graduated platform in the centre of the slide. The drop must be of such
a size that when the cover-glass is applied the blood will not run over the edge into the
trench around. Place the cover-glass on the drop of blood, and if the cover-glass
has been properly cleansed it lies so closely on the outer rim that Newton's concentna
colour rings can be observed on the cover-glass. Set the slide for a few minutes to
allow the corpuscles to settle. The platform is ruled by cross lines each enclosing a
space of J ^5 of a square millimetre ; the depth of each square with the cover-glass on
is ^ of a millimetre. The squares are marked out into sots of 16 by double lines.
Count the red cells in five of such sets — that is, in 80 squares. If the corpuscles li«
upon the lines count those on the upper and left side lines only. Calctdation for
counting red blood-cells in 1 cmm. of blood : The 400 squares equal ^\ cmm. ; 80 squares
are counted, and equal ^,^ cmm. They are found to contain, for example, 480 cor-
puscles. Adding 0000 to the number counted gives the number per cmm. For
-^ cmm. contains 480 cells ; therefore 1 cmm. contains 480 x 50 cells. But the blood
is diluted 200 times, so that 1 cmm. blood contains 480 x 50 x 200— ».e., 480x 10,000 =
4,800,000 cells.

Calculation for counting white blood corpuscles or leucocytes : The 400 squares are
counted, and contain, say, 43 leucocytes. The 400 squares are counted again, and
contain, say, 37 leucocytes. Now, since 400 squares equal ^ cmm., 800 squares
equal ^ cmm., therefore J cmm. contains 43 -f 37=80 leucocytes, and 1 omm. con-
tains 80 X 5. But the blood is diluted 20 times, so that 1 omm. of blood contains
aOx 5 X 20— I.e., 80 x 100 = 8,000 leucocytes {i.e., add 00 to the number counted).

898] BLOOD GOV NTS 649

Significance oj DimintUion or Increase of Red Celts, — In health tho average number
of rod colls per cmm. is about 5.000,000 in the malo and 4.500,000 in the female. It
is inoroased to 7,000,000 to 8,000,000 in tho nowly-bom, in plethoric persons, after
fasting and sweating, and aftor removal to high altitudes. With menstruation, child-
birth, and tho drinking of much fluid there la a decrease. In disease thoro is an incioaso
per omm. (i.) in cases in which thore is defective oxygenation in the lungs, as in chronic
lung disease or other cause of obstruction to the free entry of air ; (ii.) in oases whero
ihe blood becomes concentrated owing to loss of fluid, as after diarrhoea, vomiting,
polyuria, rapid pleural or other effusions ; and (iii.) in cases where the blood passos
too slowly through the lungs owing to cardiac insufficiency or bradycardia. In con-
genital heart disease the number may bo 10,000,000 per omm. It is also met with
after severe bums, after tho use of iron, in cholsdmia, in phosphorus poisoning, and in
the over-production following hemorrhage, and in erythremia (§ 27). It does
not occur with cyanosis per se, but only when cyanosis is accompanied by one of tho
conditions above mentioned. Diminution in number is found after hemorrhage and
other secondary anemias, and in leukemia. In pernicious anemia the diminution
may be very great, and in chlorosis very slight.

Significance of Increase or DimintUion of the Leucocytes, — In health the normal
number of leucocytes is 7,000 per cmm. (i.e., 1 white to 700 red cells). On a normal
field, with }^ English objective, and a No. 2 eyepiece, about three or four white cells
are generally seen. In the nowly-bom there may be over 17,000 and up to seven
years of age from 10,000 to 14,000 leucocytes per cmm. During pregnancy, after
meals, cold baths and exeroise, there is an increase in tho number of leucocytes.
The polynuclear neutrophil leucocytosis (§ 398) is the most usual form of leucocytosis
both in health and diseskse. In some fevers the leucocytes are increased (leucocy-
tosis), in others diminished (leucopenia). This may be of groat diagnostic importance,
especially in oases in the tropics ; such variations are described under each fever.
Generally speaking, any collection of pus will give rise to a leucocytosis ; if free exit
be provided, the leucocytosis falls markedly or disappears within thirty-six hours. If
the exit has not really drained the whole cavity, tho leucocytosis does not fall, and
this may afford an indication for further operation. Tho amount of the leucooytosis
is not proportionate to the amount of tho pus. Leucocytosis may be absont when tho
pus is well walled off, as in chronic abscesses, and also when the pationt is not reacting
to the toxin. In the latter case tho prognosis is uniformly bad. Leucocytosis is
caused by certain drugs, by convulsions of any sort, and by heat strpke. Oanoer,
except in the case of very small growths, causes a leucocytosis ; if after the removal
of a primary growth leucocytosis is found to persist or to recur after having dis-
appeared, the presence of metastases is extremely probable. The following diseases
may be mentioned as those in which the presence of leucocytosis is likely to be of
diagnostic importance : Abscess and Suppuration, Septicemia, Pneumonia, Erysipelas,
Scarlet Fever, Osteomyelitis, Malignant Endocarditis, Tubereulous Meningitis, Cancer,
and Pertussis.

Various blood diseases give rise to leucocytosis, and in these it is of importance
to study particularly which type of leucocyte is increased ; for this purpose stainir^
of blood-films is necessary.

§ 898. Mioroicopio Examination of Blood and Blood Films.— Alterations in the
shape and size of the blood-cells may be soon by examination of fresh blood-films, but
for accurate examination of the structure of tho red and white cells and a differential
count of the leucocytes it is essential that blood-films bo fixed and stained. Blood
may be obtained from the lobe of the ear by the method above described (§ 395). A
microscopic examination of fresh blood may be made by applying a clean slide lightly
to the drop of blood, placing a cover-glass on it, and examining under tho microscope*
For this method any good microscope will do with a ^ or a j^-inch English objective
(or a Zeiss's D) and a No. 2 eye-piece ; but for the differential examination of leucocytes
and for bacteria a ^-inch oil immersion lens is necessary. It is a great advantage to
have a nose-piece on the microscope capable of carrying two or three objectives, so
that one can first examine the specimen with a low, and then with a high power. It
is well to make oneself familiar with the changes the blood undergoes in a short time
after such a method of preparation. If it be desired to preserve such a specimen for

660 GENERAL DEBILIT F. PALLOR, EMACIATION [ § 898

some hours, ring the edge of the cover-glass with vaseline to prevent the entrance of
air. In this simple way we are able to note any abnormality in the shape of the red
cells, or the presence of abnormal constituents, such as particles of pigment, filaria
sanguinis hominis, or the spirillum of relapsing fever. We may also note any excess
of white cells. Rouleaux formation is also noted in normal fresh blood — t.e., the red
cells run together, leaving clear the concave spaces in which blood platelets are seen.
The white corpuscles are spherical, clear, and nucleated.

A film may he made upon a cover-glass or a slide ; for ordinary purposes the slide
method is the easier. It is essential that the slides or cover-glass be absolutely clean
and free from greasiness. Lay the surface of the slide lightly on the drop of blood
exuding from the lobe of the ear, and with the smooth odgo of another slide spread
out the blood in a ihin film by pushing the drop along the surface, so that it forms
an even film. Care must be taken not to handle the slides too much or to breathe
upon them. Allow the film to dry, and it will if necessary keep for several days
without further precautions.

In the choice of stains we employ different dyes according to whether we wish to
stain the protoplasm, or the granules of the cells, or the nuclei ; the resulting differentia-
tion of the structure and shape of the cells is of extreme importance in the diagnosis
of disease. It is usual to stain first with eosin, then with a nuclear stain such as
methylene blue. Stains are acid or basic. The common acid stains are eosin.
aurantia, and acid fuchsin ; the basic stains are methylene blue, haematoxylin, and
gentian violet. The protoplasm of the red cells takes up acid dyes only ; normal
nuclei take up basic stains. The granules met with in the protoplasm of the various
leucocytes take up different stains ; some have an affinity for acid stains such as eosin,
and are known as oxyphil or eosinophil granules ; some take up basic stains such as
methylene blue, and are called basophil granules. The granules occurring in the
ordinary polynuclear leucocyte were at one time supposed to take up both acid and
basic granules, and hence were named neutrophil granules. It is now known that
these granules take up faintly acid stains, though the cell is still named polynuclear
neutrophil for purposes of description and differentiation. The three methods of
staining which were in common use — viz., the eosin and methylene blue stain, the
eosin and hematoxylin stain, and the Ehrlioh-Biondi or triple stain — have been now
largely superseded by Leishman's method. Filter every stain before using.

Leishman's Stain, — Place the slide film uppermost upon a horizontal table, filter
enough of the stain, or Wright's modification of it, on the film to cover it evenly, and
leave for three minutes, covered with a watchglass to prevent evaporation. Pour
on distilled water, drop by drop, in quantity equal to the stain, leave for another
three minutes, and then wash rapidly under the tap ; blot dry, or allow to dry without
heating. Place on the dry film a drop of cedar- wood oil and examine under the oil-
immersion lens. The red corpuscles are stained bright pink, the nuclei dark reddish-
purple.

Variaiions of the Bed Blood Corpuscles in Disease may consist of (1) variability in
form (poikilocytosis) ; (2) variability in size; (3) nucleation. Normal red cells are
circular, bi-concave, non-nucleated discs measuring in size 6 to 8 /c, or ;v^V(i ^^ ^^
inch.

(1) Poikilocytosis (Fig. 112) is a variability in the shape of the red cells. They
may resemble a flask, a pear, or a kidney. This change used to be regarded as
pathognomonic of that serious disease pernicious anaemia; but the change is also
found in leukeemia, splenic anaemia of children, and in severe secondary ansemia such
as occurs in cancer, nephritis, and malaria. With variation in shape the red cells in
any form of profoimd ansemia appear to undergo degenerative changes — clear hyaline
spaces (vacuolation) are seen inside the corpuscles when the specimen is examined
just after removal from the body. It must be remembered, however, that such
spaces as these may also be seen in normal blood about an hour after it leaves the
body. Other more definite changes are seen in the staining of the ceUs, for whereas
normal red cells take up only acid stains, these cells take up both acid and basic stains,
bnd their substance stains irregularly. This property is luiown as polychromaUyphUid.
Basophilia or *^ stipjding " is another abnormal staining reaction of the red colls. With
a mixed dye they appear to contain minute dots staining blue. Both polyohromato-

§898]

MI0R08G0PI0 EXAMINATION OF BLOOD

551

philia and stippling are seen in ansBmio blood ; the former \r almost certainly due to
the youth of the cells and indicates not degeneration, as was formerly taught, but an
exceptional call on the marrow. The significance of " stippling '* is not so certain ;
it is one of the earliest symptoms in lead poisoning, and may follow the ingestion of
other metals also.

(2) VariabUUy in Size. — ^The normal red corpuscle measures about 7 fi ; red celb
measuring under 6 fi are termed microc3rtes, and those measuring over 8 fi, megalo-
cytes. Both variations are met with in pernicious ansBmia, leukismia, the splenic
ansBmia of children, and in severe secondary anssmia. They are also seen in severe
cases of chlorosis.

(3) Nudealed red cells are found in all cases where there is a great diminution in the
number of the red corpuscles — as, for example, in pernicious ansemia, severe secondary
aneemia ; and in spleno-medullary leukaemia even without much diminution of the
red cells. They are rare in chlorosis. These nucleated rod oells must be distinguished
from lymphocytes, which resemble them ap-
proximately in size. The nucleated red cells
differ in the more homogeneous staining of the
protoplasm. The nuclei may show karyo-
kinesis, or may be 'degenerate. There are three
distinct forms of nucleated red corpuscles : the
normoblast, about the same size as a normal
rod cell ; the large form or megaloblast, which
is about three times the size of an ordinary
red cell ; and the microblast, which is smaller
than the normal red cell. The presence of the
megaloblast in the blood is generally of grave
import, indicating the prosence of rapid ro-
generative changes in the blood. These cells
aro usually polychromatophilic {vide supra).
They may occur in large numbers in pernicious
anaemia.

Variations in the Leacocytes (Plate III.,
Fig. 1) may occur in regard to their absolute
number (blood-count, vide supra), their struc-
turo, and the relative number of one kind or
another (differential count). There are several kinds of leucocytes, and it in possible
to identify the cause of an increase in the leucocytes by the predominating variety
prosent. For this purpose and in order to make a differential count to ascertain
the relative proportion of the several varieties, it is necessary to employ the staining
method given above.

The varieties of leucocytes found in health are as follows :

In 100 leucocytes :

Polynudear . .

Small mononuclear leucocytes (lymphocytes)

Large mononuclear leucocytes . .

Transitional forms

Eosinophil ceUs

Basophil or mast oells

I ig. 112. — Drawn by Dr. Oortlou It.
Ward. Blood in pernicious ansemia ;
showing polkiJocytosis, polychroma-
tophilia, basophil stippling, a normo-
blast, and a megaloblast.

60 to 70
20 to 30
2 to 5
2 to 5
1 to 3
0-5 to 1

(1) In the Polynudear Neutrophil Leucocytes, which form 60 to 75 per cent, of all
leucocytes in the blood, and have an average diameter of 13*5 fx, the nucleus is long
and lobed, giving the appearance of being multipartite, and the protoplasm of the
cell contains fine neutrophil granules. The so-called neutrophil granules arc roally
faintly acid. This coll originates from the bone-marrow, and is actively amoeboid
and phagocytic (microbe devouring). (2) Lymphocytes, 20 to 30 per cont., are small
cells without granules, with one large nucleus and very small amount of surrounding
protoplasm : coming chiefly from the lymphatic glands and adenoid tissue. They are
neither amoeboid nor phagocytic. (3) Large mononvuiear or " hyaline " cells have one
large spherical nucleus and a larger amount of protoplasm than the lymphocytes.

652 GENERAL DEBILITY. PALLOR. EMACIATION [§

These cells are supposed to oome from the bone-marrow, and are slightly amoeboid.
(4) Eosinophil polynudear leuoooytes, with coarse, oosin-staining granules, coming
from the bone-marrow, are amoeboid, but not phagocytic. (5) Basophil leuoooytes,
or mast cells, with coarse basophil granules. (6) Transitional forms between (3) and
(1 ) above are found. Their nuclei are faintly stained, and of a horse-shoe shape.

Variations ol Leacocytei in Disease. — Variations in the number of the leucocytes
in health have been referred to (p. 551), and a number of causes of simple increase in
number of leucocytes has been given. Polynudear neutrophil leucocytosis is the
commonest form of increase of the white cells. When leucocytosis is present, a difier-
ential count is desirable ; the disease may often be diagnosed by the predominant
variety present. At least 500 leucocytes must be counted, the number of each variety
noted on a piece of paper, and the percentage of each calculated. In many cases it
may be necessary to make this count daily — €,g., to watch the steady daily increaee of
polynuclear neutrophil cells, which may denote a perit3rphlitic or other obscure abscess
within the body. Except in leuksemia, leucocytosis rarely passes beyond 100,000
per cmm. (normal about 7,000 per cmm.).

(1) The Pdynvdear Neutrophil cells constitute, as just mentioned, the majority of the
white cells in the blood. They are greatly increased in infective diseases, suoh as
pneumonia, septicsemia, erysipelas, cerebro-spinal meningitis, scarlet fever, and in local
inflammations or abscesses such as appendicitis and osteomyelitis. So tme is this
that an unfavourable prognosis in croupous pneumonia can be based upon an abeenoe
of leucocytosis. In typhoid fever the onset of a suppurative complication may be
diagnosed by the presence of an increased number of polynuclear neutrophil leucocytes.
A diagnosis may be made between typhoid fever and tuberculous meningitis from the
fact that in meningitis there is leucocytosis, but there is none in typhoid fever un-
complicated by abscesses. If leucocytosis be found, even without definite physical
signs pointing to an inflammatory condition, the onset of inflammation can almost
with certainty be predicted. In this way blood examination comes to be of the
highest importance in the diagnosis of obscure abdominal cases, as a polynuclear
increase is rightly regarded in such cases as an indication for operation. The blood
signs of deep-seated suppuration are increasing leucocytosis, with a high percentage of
polynuclear leucocytes, increase of blood platelets, and glycogenic degeneration of
white cells — ».e., staining with iodine. In cancer of the stomach it has been found
that there is often no increase of leucocytes one hour after meals, as would occur in
health or in simple ulcer of the stomach. In all severe stomach trouble leucocytosis
after digestion is diminished or absent. After profuse haemorrhage and in malignant
cachexia leucocytosis is present. The subcutaneous injection of irritants also pro-
duces leucocytosis.

(2) The increase of eosinophil cells occurs in one form of leuksemia (see below), in
several skin diseases, notably pemphigus and psoriasis. In asthma they may be in-
creased to 25 per cent, or more, and this may be an aid to its diagnosis from cardiac
disease and mediastinal tumour. Local accumulations of eosinophils also occur in
the bronchial secretion of asthma and sometimes around oancer growths. Eosino-
philia is found in those suffering from hydatid, trichinosis and ankylostomiasis ;
indeed, in obscure cases its presence may give the physician the clue to search for
parasites. It occurs also in chorea, Hodgkin's disease, and after tuberculin injections.

(3) Lymphocytosis (increase of lymphocjrtes) occurs in lymphatic leuksemia (90 per
cent.), whooping cough, tuberculosis (except meningitis and sometimes acute miliary
tuberculosis), and after secondary syphilis. The diagnosis of Hodgkin*s disease from
lymphatic leukeemia may depend upon the examination of the blood. In the former
there is no leucocytosis, or fi present there is an increase mainly of the polynuclear
leucocytes ; in the latter the lymphocytes are greatly increased.

(4) The great increase of large monomjLclear cdls in cholera aids in the diagnosis of
this disease from other causes of acute diarrhoea in the tropics.

(6) Other forms of leucocytes which make their appearance in disease are (i.) myelo-
cytes, very large cells, mononuclear, some with fine neutrophil, some with coarse
eosinophil granules, coming from the bono-marrow. Myelocytes occur in the splono-
myelogenous form of leukaemia in large numbers (30 per cent.), and in anaemia splenica
infantum, and in all diseases in which there is an excessive call upon the blood-forming

}S99]

PARASITES FOUND IN THE BLOOD

553

activities of the bone-marrow, (ii.) Immature colls of various sizes and staining
reactions may bo seen in similar conditions.

MeUmsBmU is a term applied whon certain pigment granules occur in the blood
after ague, relapsing fever, and some melanotic tumours. They appear either in
minute black lumps, or are onclosed within the colls.

lodophilU. — In suppurative and other disorders the plasma of the leucocytes has
an affinity for iodine. Place the blood-films in a stoppered bottle containing crystals
of iodine and leave for two hours ; then examine under a high-power lens. If iodo-
philia is present there aro black dote or a diffuse dark coloration in the leucocytesg
In a normal film the red cells aro stained orange, the leucocytes are unstained. The
reaction is said to depend upon the presence of glycogen in the plasma. By this
method the presence of organic disease may be diagnosed in obscure cases.

Blood Plateleti.— As yet no clinical importance has been attached to the blood
platelets. They are frequently not observed in the ordinary methods of blood
examination. In order to find them a cover-
glass must be placed on a slide, with the
edges of both corresponding. Place the edges
near the forming drop of blood, which by
capillary attraction will immediately spread
out into a film. Stain with Leishman^s stain
or methylene blue. The blood platelets are
seen with ^^-inch oil immersion lens as irregular
bodies, small, apt to run together in clumps.

Blood Dust is a term which has been given
to a number of small clear bodies in the blood,
with a vibratile motion, about ^ to 1 m in size.
They are supposed to be granules extruded
from neutrophil and eosinophil cells.

§ 899. Pansitef found in the Blood.— The
MiOBO-OROANiSHS which can be detected in
the blood (such as glanders, anthrax, septic
microbes, the spirillum of relapsing fever, the
typhoid and influenza bacillus), and their
methods of detection, as far ae it is applicable
to clinical work, are referred to in Chapter XX.

The chief pabasitbs which have been found
in the blood are the filaria sanguinis hominis,
distomum hssmatobium, the malaria parasite,
the protozoon of kala-azar, and the trypano-
Boma.

The Parasits of Malarial Fbvbb is a
protozoon, inhabiting the red corpuscles,
which it destroys, but it does not invade
other tissues. There are three well-marked
varieties of the parasite, distinguished from
each other by their intraoorpuscular de-
velopment, and these varieties correspond to the three types of malaria known as
benign tertian, quartan, and malignant tertian fever. The life-history of the proto-
zoon runs through two stages : (L) The asexual or intraoorpuscular stage in man ; and
(ii) the sexual form within the body of a mosquito belonging to the genus anopheles
(Fig. 100, § 378). The tertian parasite, which gives rise to the benign form of malaria,
is the least virulent (Fig. 113). It is first seen within the corpuscle as a small, clear,
ovoid body about 2 /4 in diameter, possessing active amoeboid movement. It gradu-
ally increases in size, and after the lapse of a few hours becomes ring-shaped, with very
finely granulated pigment collecting about its centre. In the benign tertian form
there is at the same time marked enlargement of the corpuscle, with a striking decrease
in its colour. At the stage of full growth the parasite occupies nearly the whole of
the enlarged corpuscle, and now it may follow either of two lines of development:
(L) The pigment gathers as a solid mass in the centre of the parasite, the protoplasm

Fig. lis.— Parasith of BCalarial
Fbvbr.

1 to 4 - stages in benign tertian ; 5 =cre8'
cent body ; 6 = oval body ; 7 = flagel-
lated body.

654 GENERAL DEBILITY, PALLOR, EMACIATION [§

divides by a radial arrangement into well-marked roBettes of from fifteen to twenty
segments ; these disintegrate as spores, and masses of insoluble pigment enter the
blood-stream. This phase is known as " segmentation **; it is complete in about
forty-eight hours, and corresponds clinically to a fresh paroxysm of the fever. The
intracorpuscular development just described is asexual, (ii.) The sexual development
takes place in the female mosquito, which sucks the blood of a malarial patient, and
takes into its stomach the protozoon in the phases above mentioned. All die except
the male and femal* gametocyte (which are crescentic in the malignant tertian type),
the female being distinguished by the pigment round the nucleus. The male gameto-
cyte develops within the mosquito into a flagellated body, and one of the flagella unites
with the female gametocyte to form an oval-shaped body with pointed ends. This
projects from the stomach wall of the mosquito into its body cavity, and becoming
spherical it subsequently divides into numerous cells, and thbse again into curved,
needle-shaped bodies. These are carried by means of the salivary gland of the moe-
quite into the blood of the person bitten, and so into his red blood corpuscles.

The parasite of the malignant tertian fever is first seen in the red blood-oeUs as a
tiny, impigmented, hyaline body, forty-eight hours being needed for its development.
At first it exhibits enei^tic amoeboid movements, but ultimately settles into a bright,
colourless, ring-like form, with one or two pigment granules contained therein. There
is frequently multiple infection of the rod corpuscles, which at first enlarge, tlien
shrink, and become a brassy hue. The rosette or sporulating stage is rarely seen.
In about a week (during the period of remission) characteristic crescent bodies, con-
taining masses of coarse pigment granules, begin to appear, and increase in number
rapidly. They are incapable of sporulation, and represent the sexual form — the
gametocyte.

The quartan parasite, the easiest form for the beginner to study because of its
visibility, first appears as a small, round, clear speck, resembling a vacuole, but witli
feeble amoeboid movement. It takes from sixty to seventy-two hours to complete
its cycle. By the third day pigment, coarser and blacker than that of the tertian
form, gathers round its periphery. On the fourth day segmentation takes place,
the pigment flows in towards the centre, and hero forms the radiating lines which
produce the beautiful ** daisy rosette " so characteristic of the quartan parasite. It
breaks up eventually into eight to ten spores, and these with the insoluble pigment
become free in the blood-stream. The development of the gametocyte resembles
that of the benign tertian variety. There is no enlargement of the red corpuscle.

Staikikg is not absolutely necessary for the detection of the parasite, which appears
as a clear ovoid body within the red ceL. Sir Patrick Manson*s rules should be
followed. It is best to examine the blood unstained at first, just before or during a
rigor. Method, — The first drop or two of blood must be wiped away, and a clMin
cover-glass applied to the summit o': the next drop, then lightly placed on a slide.
The blood should then show areas within several zones ; if these zones do not appear
it is simply waste of time to examine the specimen. To prevent evaporation and
crenation it is well to ring the glass with vaseline. The zones are : (1) A central or
empty zone ; (2) a zone of isolated or scattered corpuscles ; (3) a third zone, in which
the corpuscles lie closely together, the ** single layer ' zone ; (4) beyond tJiis the
corpuscles lie upon each other, the ** heaped up '* zone. Look for the parasite in the
** single layer " zone. To stain, employ Leishman's method. The parasites are
stained bright blue, with nearly black granules (Plate III.).

BiLHABZiA HjDfATOBiA (or distomum haematobium) is a trematode giving rise to
recurrent hematuria (§ 300), inhabiting the blood of most of the Fellah and Coptic
population in £g3rpt. The ova are extremely plentiful in the urine, and are very
characteristic ; they measure 12 ^ long by 4 ^ broad, are spiked at one end (Fig. 89,
§ 300), and occur in the blood and in some of the organs ; the parasite itself is found
in the portal system, especially in the venous plexuses about the rectum and bladder.
. FiLABiA Sanguinis Hominis is a parasite which occasionally produces elephan-
tiasis, ohyluria, etc. The method of revealing the embryo is to allow a thick drop of
blood spread upon a slide to dry. Stain half a minute in a 2 per cent, solution of metiiyl
blue. Decolorise if necessary in dilute acetic acid (4 drops in 1 ounce of water), and
examine with low power (see Fig. 1 14). Six species of filaria are known to infect man.

§ 3»8] PARASITES FOUND IN THE BLOOD 656

(Ij The FHaria Bancrofli vel Fiiaria ^^ocIuftki very rarely causes any pathological
aymptoins in the ombryoaio stale. The embryos may be found in 20 p<>r ceat ot
apparently healthy leeidenta in Barbadoea and other tropical cUmalea. The embrya
comes into the peripberal blood at night (from 6 p.m. to 10 a.m.) ; tbeir maximum
□umber is usually found about midnight. It may be necessary to make rapeated
examinations at intervals of two hours to be able to find them. During thp day the
fiiaria go into the lung bloodvessols where they are usually found in autopaies of
people who bod them, and died in the daytime. Should a victim of the parasite
altar his usual habile, and sleep during the day, the Slaria periodicity is reversod.
Tho adult fiiaria inhabit the lymphatics, where they give birth to immense aambera
of embryos, a laifp number of which must in some unknown way disappear, or else
the blood would contain them in incalculable numbera. Embcyos show a very active
moventent, but this is witbin thbir abeatb, so that there is no locomotion properly
apesking. It is this motion of their sheaths which keopi the blood corpuscloe moving
away from the parasite. Sometimes those embryos are actually seen escaping from
tlieir sheath, and then they become locomotive. The parasite is about >j of an inch
in length by ^^J,in of an inch in diameter. The sac prevents
tho creature from piercing the walls of the blood veseels, and
tbuB gives it the chance of gaining accisB to tho body of
a mosquito, where it uadorgooa a metamorphosis, resulting
in the formation of a mouth, alimentary system, and a
Irilobed taU. It grows mitil it becomes ,',, of an inch in
length, ro.entors man, and grows to tho mature stage of ite
existence. Adult parasites after their death cause well-
marked eymptoms — viz., various forms of elephantiasis,
lymphacrDtum, hsmatochyluria, chylous diarrhoaa and
ascites, usually related to their blocking of the lymphatic
circulation.

The other species are ; (2) Fiiaria Ffrslam ; (3) FHafia
Demargnaii ; (4) Fiiaria Otzardi ; and (S) FUaria Loa (pro-
bably the adult form of Fiiaria JJiutna), which are found
in the connective tissue, subcutaneous or subperitoneal, and
are not known to give rise to symptoms. (6) Fiiaria Ditirna
ia of the same dimeosious and anatomical characters as
hlaria noctuma, but it is found in the blood of patients
during the day, and not in the night.

TBiPABoaom.— The paiasite of iryponoaomituw (§ 386),
is a flagellat«d protozoon (Fig. 115). It is usually ob.
tained in trypanosomiasis by gland puncture, and can
also be found in the cerebro-spiual Quid. It is a minute
worm-like organism found free in the blood, moving with

a screw-like progresa. One end of the parasite is drawn pij. ii4.— fiiaria 8iN-
out into a whip-like process, the flagellum ; the other end omiiu Hominis.

a bluntly cooical ; tho body itaolf is short and thick, and

its substance granular. Attached to one side ia a transparent, flange-like procu^,
the undulating membrane. Atits posteriorend ia a highly refractile spot, the vacuole.
The length of the parasite, including the flagellum, is about 18 /i t« 26 ^. It is best
sbtined by Leishman'a or JEiomanowaky's stam.

The protozoa of Kai^-azar are found in tho spleen, liver, bone-marrow, the blood,
and in the lymphatic glands from the mesentery. They have been chiefly studied in
blood and pulp withdrawn from the spleen, oT proftrably the liver during life. Tho
oommonest form found is a small ovoid body longer than it is broad, below 2 ^ in
diameter, measuring about one.^th of a led corpuscle in its longest axis. It conlaina
tiro nuclei ; one is small, rod-shaped, and stains deeply ; the other is larger, rounded,
and stains leas deeply. Other forma met with consist of small groups of similar bodies
clumped together, resembling a quartan aporulating malarial parasite ; at times these
are seen breaking up into the simpler fonns. A still earlier stage of this spomlisatinn
is seen, in which paint of unequal mziil niuloi am gruu]J<nl within a niiigle cell, but with
no signs of division apparent. They are iutiocollulac, and distend thu red bkiod-cell

656 OESESAL DEBILITY. PALLOR. EMACIATION [J4M

until it burato. Tbo; stain fftintly with ntethykae blue ; but tho best method oF
Btaining them ia by Leiahman's or Kamanownky'R stain. Tho same bodies hsve beoii
found in Delhi boil and infantile aplenomegaiy. They are known u Leiahnian-
Itonovau bodiee, ^nd oulaido Ihit body thuy elongate and dtinjlop a Hagollum.

£400. PhT«ic*l and Chemical Ptop«rtiM ol the Blood. -Tho alkalinity or thk
BLOOD can be teiftud by mothoda which can only bo poriormod in a laboratory. Thi;
blood is nevoc acid to litmus, but tho di^grfv of ita ailialinity varies. It is greater in
men than in women and children ; it ix dimitiishoil after viol<;nt oxsrciso and tho pro'
longed UBu of acidii. and it in incr«asi-d At llin bnginning of digestion, and aiter the
prolonged use of alknlics. In diseawi thorn in diminished alkalinity found with
leuk«mia. pomicious sncmia. ansmia. diabetes, cancer, great cachexia, poiwning
with carbon monoxidu and with acidt>. high feiirr^, and various toxic proooaoei. Id
ehlorosis it is little if at all diminished.

The normal SPECiric gravity of the blood 19 approximately 106S. It may be
ostimatod by mixing chloroform and benzol till the speoiGc gravity of the mixteie
reaches 1055, and adding to this mixture a drop of blood from a pipette. If Uie drop
remains without rising to tho surface or falling to the bottom the spnaific gravity of
the blood is 1056. If it sinks, continue to add chloroform drop by drop, shaking tJie
mixture the while, until tho drop becomes suspended. If it lloata, add benzol until
tho drop is suspended. Then take the specific gravity of tho mixture, and this is the
eame as that of the specimen of bkiod.

SignificuTice oj Altered Specific Qravity, — The amount of htemoglobin can be esti.
mated by finding the specific gravity of the blood, because it has been foond that
the Bpooifio gravity varies in proportion to the amount of hBmoglobin present, but this
is of little practical value. Major Leonard Rogors examines the speciGo gravity of tho
bk>od in cases of cholera as a guide to the frequency and amount of injections of tho
hypertonic saline solotioos which he has found so efficaoious for that dimaee. He
employs a miituie of glycerine and water, which can be obtained in bottles, with
full directioiis. from Messis. Down Bros. In the acute stage of cholera the specific

SWO] PHYSICAL AND OUEMWAL PROPEHTIKS OF THK BLOOD 567

gnvity varias belwnen 1060 and 1072 ; an injection is indicated whon the roading is
over 1066.

Sfbctrosoopic Exajuhation of tJie blood. — The inatnunent chiefly used for
clinical pntposee is Bratmmg'a spectroscnpo. It is lued by holding up a glass von-
tsining a Tei7 dilate solution of blood, andlooking throughitat tbelight. of ata>vhite
cloud with a apoctroecopo placed between the blood solution and the eyea. HeBinoto*
porphyrin (Fig. 116) has been found in tho urine insulphonal poisoniag. The discovery
of nieUueiaoglabin in tbs blood toay be a means of warning the physician of tilo near
onset of eoma in diaooaoa such as unemia or diabetes. Mothiemoglobin is fofmed in

Fig. 11«.— Drawn bj Dt. Ootdon R. Ward.
I. OxybamoctablD — normal ipectmni oJ (re«h blood, i. Sjwctnun of CO-li*nio«lobin. Prs-
parcd by paHlim coal gaA throaeh normal blood. 3. Spectrum of mfltluemoglobtn. Foond
Id tho blood of aome caaea of " Entetogenoiu oyanotls," in acut« polionlng with varloiu
juilUnc dertvaUTce and other drutn, and tn the urine or HsmogLoblnuris. On the addition or
Atnmonlam gnlphlde the apectrnm chani^cB to No. 10. 4. Spectrum of Sulph-hemoglobln.
Found In the blood In lame cases of " En(«rogenDDi cyanaeli." It la not altered liy the addi-
tion of imall qaontltlva of Ammonium aalphidc. 5. The chancterutJc change produeed In
the apectrum of Snlph-hiemoglobin by puslng through it coal Ras. All the bands are ahltted
towsrda the bine end of the spectrum, e. Theeprctrum of Ha^mHtoporphyiin In add anlutlon.
Pound in the nrlnn In aulphonal pDlionins, etr. T. The speclrum of urobilin. This Is a
product of the destruction In the hody of red blood corpuaoles — i,f.. of htemolyali. It la
found Inoreoied in the urine in many cases of Pernicious Aniemla, in L'holetula, etc. S. The
spectrum of acid hsmatiu. rroduced by the decompo^itloii of blood in acid solution. It is
Important to demonstrate thia spcetrum when It la desired la ascertain whether a given aub-
atanCB Is blooS. 9. The spectrum or Hisnioelironiogen or reduced hBmatin. Prepared by
dbaelving the anapected pigment In potaasium hydrate and then adding Ammoniiiin sulphide.
The spectrum Is eoaily demonstrated and very characteristic. 10. The spectram of Haemo-
globlu, sometimes called " reduced Hnmoglobln." Tlie coloorlng matter or blood deprlveil
□( Oxygen ; it exists In venous blood. Noa, S and S are Important In medico-legal l«st4.

nitro-biinEol and potaBaium chloiat« poisoning and other oonditions (} 28) ; and
oarbozyhnmoglobin in coal gs« poisoning.

The CoAQDi^BiUTY or THE BLOOD is ostimatod by Sir A. E. Wright's ooagulo-
meter.^ It has a number of tine tubes, into which blood is drawn at definite intervals,
and at varying times the operatiir blows down the tubes. When the blood cannot be
blown out it has ooagulated. The coagulation time is thus readily calculated. Co^^-
lation depends upon the presence of lime salts and fibrinogen, which are oontainod in
the blood plasma, and of nucUo-proteid, which is contained in the substance of the
leuoooytM and blood platelete. The nucleo-proteid is liberated when the leuoocytes
are dinntegratfld, and thia may occur when infective toxins circulate in the blood,
> Hawksley supplies the instrument, with directions.

658 GENERAL DEBILITY, PALLOR, EMACIATION [§401

when the bloodvessels are diseased, and in cachectic states, and thus thrombosis may
in some cases be explained. Coagulation within the body is also hastened by the
addition of certain salts, such as calcium chloride. Coagulation within the body is
diminished in certain infective diseases, and in urticaria, prurigo, and allied eiytiie-
matous conditions, and the administration of calcium chloride in 20-grain doees. as
the author has shown, ^ is of great use in alleviating prurigo and urticarial conditions.

The Feeezino-Point op the Blood is normally 0-66'' C. It is lowered to 0-60** C
in cases of renal disease, in which an excess of urea and salts is present, and reaches
0*8** C. in cases of impending ursemia.

PART C. DISEASES WHICH GIVE RISE TO GENERAL DEBILITY, WITH
OR WITHOUT ANEMIA AND EMACIATION : THEIR DIAGNOSIS,
PROGNOSIS, AND TREATMENT.

§ 401. Routine Procedure and Classification. — Here, as elsewhere, we
have three points to investigate :

First, the Leading, and perhaps the only, Symptom complained of bv
the patient will be debility, or pallor of the skin, or loss of flesh.

Secondly, the^HiSTORY oy the Illness, its date and mode of onset and
mode of evolution. Often these data are vague, but special inquiries
should be directed to the condition of the digestion in times past, and any
other pointB relating to nutrition.

Thirdly, the Physical Examination of the patient, commencing with
that physiological system to which the results of our previous inquiries
have directed attention, and then going through all the systems seriatim.
An examination of the blood should be made in all anaemic or doubtful
cases — ^viz., blood-counts, heemoglobin, and films.

ClassiflcatioiL — If anemia is suspected or pallor of the skin is the
leading symptom, turn first to Group I., below.

If LOSS OP FLESH is most prominent, turn to Group II., p. 587.

If GENERAL DEBILITY (without obvious pallor or loss of flesh) is most
prominent, turn to Group III., p. 593.

GROUP I. ANEMIC DISORDERS.

Anaemia is an alteration in the composition of the blood, the leading
character of which is a deficiency in the haemoglobin. The disorders
giving rise to pallor of the skin arc :

CoMMONEB. Raber {in this country).

I. Chlorosis (primary anaBmia), § 402. With Signs in Spleen and Lymphatic

II. Pernicious ansemia (§ 403). Glands.

I. Leukssmia (§ 407).
GonstUtUional Conditions. I^- Hodgkin's disease, or lymphade-

V. Tuberculosis. With Signs referable to Skin.

VI. Carcinoma. jy g^^,^ (j ^^qj

V. HffimophUia (§ 411).
yi. Addison*s disease and other maladies
mentioned in Groups II. and III.

1 The Lancet, August 1, 1896.

§402]

ROUTINE PROCEDURE : GROUP I.— PALLOR

550

AnoBmias of Infancy.

I. Primary ansBmias.

II. Secondary ansemias.

III. Congenital ansemia.

IV. Infantile scurvy.

V. Ansemia splenica infantum.

Ck)MMONBR. Rabbb {in this country).

Visceral Disorders. With Typical History.

VII. Gastro-intestinal conditions. yil. Malaria and other tropical and
VIII. Chronic aortic disease. parasitic diseases.

IX. Chronic renal disease.

X. Chronic hepatic disease.

Recognised by History.

XI. HsBmorrhage, hyperlstctation, and
other causes of long-continued
drain.
XII. Post-febrile ansemia.
XIII. Chronic suppuration, septic pro-
cesses, and lardaceous disease.

The first two disorders given in the list are called primary, essential, or idiopathi
ansemias, because they are not known to be preceded by any other disease (such a
tubercle, malaria, etc.) ; all the others are csJled secondary ansemias. The division
into idiopathic and secondary ansemias is somewhat artificial, and idiopathic ansemia,
the ansemia of unknown causation, will probably disappear with the march of science
just as idiopathic peritonitis has done. This, like all the other ansemias, is the result
of a defect of the hsemogenic or the hsemolytic functions of the body, about which we
shall probably know more in the course of a few years.

Among the various members of the list, the pallor may present to the experienced
observer a difference in kind and degree in the several affections. Thus, the greenish-
yellow colour of chlorosis, the lemon-yellow of pernicious ansemia, the earthy tint of
carcinoma, the sallowuoss of aortic disease and interstitial nephritis, the pasty white
of parenchymatous nephritis, and the transparent waxy look of lardaceous disease
are very suggestive to the careful observer. The microscopic examination of the
blood a\ao reveals differences which are mentioned below. Among the commoner
ansemic disorders it will be observed that after the two primary ansemias come four
constitutional conditions, then four visceral disorders, and finally the three conditions
which are readily recognisable by their history. The age of the patient will often give
us a valuable clue.

Among the (in this country) rarer disorders, leuksemia, lymphadenoma, and splenic
ansemia present physical signs referable to the spleen or lymphatic glands and leuco .
cytosis ; scurvy, hsemophilia, and Addison's disease present signs referable to the
skin ; and the remainder reveal a history of tropical disease or parasites.

The blood shows marked diminution of hsemoglobin and other changes, and
there is no discoverable primary organic lesion. The disease is prob-
ably Chlorosis or Pernicious Anemia ; the age and sex of the patient
and the colour- index of the blood being very different in the two diseases.

§ 402. I. Chlorosis (" green sickness," " poverty of blood," sometimes
spoken of as primary, essential, or idiopathic ansemia) is a chronic malady
in which the main feature is a diminution of the colouring matter of the
blood, imaccompanied by any gross lesion, not preceded by any primary
or causal disease, and occurring mostly in yoimg women.

The chief Symptoms are (1) failing strength of vague onset and con-
siderable duration, accompanied by pallor of the surface, but unaccom-
panied by wasting. There is, indeed, often an excess of adipose tissue.
The pallor is marked in the lips, gums,and conjunctivfle (as may be observed
by pulling down the lower lid), and the sclerotics have a bluish colour.
The skin sometimes presents a greenish hue, hence the name chlorosis

500 GENERAL DEBILITY, PALLOR. EMACIATION [§402

(;(Ao/x)§, green). These patients generally present themselves on account
of either cardiac or digestive symptoms, headache, or amenorrhoea.
(2) Cardio-vascular symptoms, such as dyspnoea on slight exertion, palpita-
tion, and a tendency to syncope. In a fair proportion of the cases enlarge-
ment of the area of cardiac dulness can be made out. Haemic murmurB
are heard, especially over the pulmonary area. In marked cases the
" bruit de diable " is to be heard — a continuous hum heard when the
stethoscope is gently placed over the jugular vein in the neck. (Edema
of the ankles at night is common, and venous thrombosis may be met with.

HsBmio or Anssmio Murmnii may be either systolic or double in rhythm, never
diastolic alone or presystolic. They are usually soft and blowing, but may be ex-
tremely loud and rasping ; loudest in the pulmonary area, but they may be heard all
over the precordium, very rarely in the a^a ; often louder when the patient is lying
down or has rested, and apt to vary from day to day.

(3) Disturbances of digestion are generally present, such as deficient or
capricious appetite, and discomfort after food ; and there may be atonic
dyspepsia, gastric atony, and gastroptosis. Intractable constipation
often precedes and accompanies the a£Eection, and was once believed
to be its principal cause. (4) Symptoms referable to the nervous
system, such as headache, neuralgia, tinnitus, vertigo, defective attention,
nervousness, irritability or depression of spirits, spots before the eyes.
(5) Amenorrhoea is usual, dysmenorrhoea not infrequent ; menorrhagia
rarely accompanies chlorosis. The thyroid may be enlarged, with other
hyperthyroidic symptoms at times. (6) Some authorities say that chlorosis
may be attended by elevation of temperature from time to time, but
adequate proof in the post-mortem rooni should be forthcoming that such
cases have not been due to some undiscovered syphilitic, tuberculous, or
septic lesion {vide p. 522, footnote). In ordinary cases the temperature is
subnormal. (7) Blood changes, — There is usually but little diminution in
the number of red corpuscles, though a great diminution in the haemoglobin
which they contain. The red corpuscles appear pale, and the total hsemo-
globin in the blood is sometimes as low as 30 per cent, of the normal. In
severe cases, however, there is also a considerable diminution (down to
2,000,000) in the number of red corpuscles. Poikilocytosis, polychrom-
atophilia and nucleated red cells are imcommon except in severe cases
(see § 398) ; chemical analysis shows a marked diminution of the iron in
the blood. There is an excess of the watery constituent of the blood or
" hydraemic plethora."

The Diagnosis is not, as a rule, difficult, by reason of the age and sex
of the patient. The pallor of the skin, though it may have a yellowish-
green tint, is usually quite different from that of jaundice or the cachexia
of malignant disease. It has at times to be differentiated from that due
to any of the conditions mentioned in the succeeding sections below, and
especially from gastric ulcer. The chief danger is lest an early stage of
chronic tuberculosis should be overlooked ; and to avoid this a thorough
examination of all the organs should be made, the principal physical signs
in chlorosis being the murmurs and the pallor. The pallor of renal disease

S 40e ] OBLOROatS 661

is an ivory white, and is attended by albuminuria, tube-casts, and in some
forms by generalised dropsy. Chlorotic girls may have oedema of the
ankles, but there is no albumen in the urine. The diagnosis from organic
heart disease is given under Cardiac Murmurs (§ 47).

Prognosis, — The disease is rarely fatal, but it is extremely liable to
relapse, and the symptoms are sometimes so grave as to necessitate strict
confinement to bed. It is essentially a chronic condition, and its course
always extends over many months, imless checked by treatment. Recur-
rences are conmion. Gastric ulcer may follow. Thrombosis of the
femoral vein may occur, and, occasionally, of the longitudinal sinus. Optic
neuritis may occur with recovery, but ocular paralysis and proptosis, due
to intracranial thrombosis (Hawthorne), are usually fatal signs. " Spurious
haemoptysis"— ».«., hromoptysis without any pubnonary mischief— prob-
ably coming from the mouth or throat, occurs occasionally.

Etiology, — ^Apart from relapses, the disease is practicaUy confined to
young women between the ages of fifteen and twenty-five, who suffer from
constipation, and have not sufficient out-of-door exercise or fresh air. It is
a curious and unexplained circumstance that more blondes than brunettes
are affected. The disease has at different times been thought to be due to a
smaU aorta, the onset of puberty, chronic constipation, or the wearing of
tight corsets. It is probably due to a defective internal secretion. It was
suggested that in constipation the iron in the food does not reach the
system, owing to its decomposition in the alimentary canal and its com-
bination with sulphur to form sulphides, but this theory, like others,
remains unproven.

The Treatment of chlorosis consists, first, in correcting any digestive
trouble which may be present, or constipation, or intestinal sepsis (e.^., by
naphthol or salol) ; secondly, in the administration of iron ; and thirdly,
in adopting hygienic measures, especiaUy such as promote oxygenation.
It is well to remember that at least three months are required to effect a
cure, and the patient should be warned of the danger of relapse. Iron
should be administered in sufficient quantities and in gradually increasing
doses (e.g., one Blaud's pill, P. 86, thrice daily for the first week, two for
the second, three for the third, and so on for five weeks, then decreasing
the dose). Liq. ferri perchlor. (m. 5 to 10) is a very valuable remedy, if
the stomach will tolerate it, on account, it is said, of the amount of free
chlorine given off, which acts as an intestinal antiseptic. It may be com-
bined with magnesium sulphate. Ferri sulphas (alone or with aloes),
1 grain thrice daily for the first week, increased to 2 grains for the second
and 3 grains for the third, continuing at 9 grains per diem for three months,
will seldom fail to effect a cure. If nervous symptoms be present, syrupus
ferri phosphatis is useful ; while anmionio-citrate or peptonate of iron or
reduced iron may be given to patients with delicate digestion. When
monorrhagia is present, treatment directed to this condition should be
adopted (§ 322). If the case resists iron and arsenic in one or another form,
the diagnosis should be revised, and tubercle or one of the other conditions

562 OMEiiAL MBlLlfy, PALLOR, EMACIATION [ } 4M

mentioned below considered. Other remedies include arsenic, Levico
water (which contains iron and arsenic), cod-liver oil, lacto-phosphate, malt
extract, manganese preparations, dilute acids, and the administration of
oxygen. Hypodermic injection of iron is much in vogue on the Continent,
and good results are reported therefrom. Rest in bed is necessary in
severe cases, and complete rest alone in many cases is of great benefit.
The curative effects of fresh air must in nowise be forgotten. The patient
should sleep with window open, and be always in the open air. For
mild cases gentle exercise for both mind and body should be prescribed.
Late hours, tight lacing, overstudy, worry, and idleness are to be for-
bidden. To enlarge the capacity of the chest prescribe respiratory exercises.
The diet must be liberal, especially in regard to nitrogenous food in the
form of butcher's meat (which should be taken at least once daily), and
milk. Green vegetables and fruit are useful. The patient should avoid
drinking much at meal times ; half a tumbler of fluid is sufficient. Two
to three hours after food a timibler of hot water may be taken. The
food should be carefully masticated, and the teeth attended to if necessary.

§ 408. II> Pernicious Anssmia (Synonyms: Idiopathio Aniemia of Addison, Addi-
sonian AnsBmia) is a relatively rare variety of primary anaemia first^desoribed by Addison
(who called it idiopathio anaemia), and now known to bo associated with certain other
signs of toxaemia and of haemolysis, chiefly affecting men in the second half of life,
and ronning a chronic and generally fatal coarse. The principal changes constantly
present after death are : The heart exhibits fatty degeneration ; the spleen is engorged ;
the bone marrow is unduly red, and contains a great number of nuclej^ted rod cells,
especially gigantoblasts ; and the liver is fatty, sometimes enlarged, and contains an
excess of iron deposited within it, as shown by the ferrocyanide reaction. Extensive
atrophy of the gastric mucosa may also be found. Changes have been discovered
in the sympathetic ganglia, and in the posterior columns of the cord.

The Symptoms may be divided into two groups : (1) Those due to anaemia per se,
and (2) those peculiar to ** pernicious '* anaemia. Among the first group are : Qeneral
weakness and anaemia of insidious onset, with their usual effects — ^palpitation, dyspnoea,
a tendency to syncope, haemic murmurs, and other symptoms as in chlorosis {q.v.).
There is little if any wasting ; there may, indeed, be much subcutaneous fat. Among
the second group are : (1) General toxic symptoms, such as lassitude, irregular pyrexia
from time to time (though the temperature at other times may be normal or sub-
normal). (2) Gastro-intestinal attacks with abdominal pain, comparable in severity
to the crises of tabes. Diarrhoea may resist treatment and cease with improvement of
other symptoms. The tongue is sore, due to an atrophic gastritis ; this may be
the first symptom of the disease, and the patient may be able from its presence to
foretell relapses. (3) Nervous symptoms, varying from slight ataxy to paralysis of
all the limbs, due to sclerosis of the spinal cord. Sometimes these precede the anaemia
and occasion difficulty in diagnosis. (4) Symptoms due to haemolysis — e,g., anaemia,
with urobilinuria, excess of uric acid in the urine, and a lemon tint of the skin. (5 ) Thpi\>
is a marked tendency to haemorrhage, especially into the retina, sometimes into tho
skin, and from the mucous membranes into the internal organs. (6) Blood chanjeg
(§ 398, Fig. 112). (a) The red corpuscles are much reduced in number, oft^n
falling to less than one-fifth of the normal. (6) The colour index is high — t.e., the
percentage of haemoglobin in each corpuscle is increased, but tho total haemoglobin in
the blood is diminished — e.g,, it may be as low as 8 to 15 per cent of the normal,
(c) The most frequent alteration in the blood consists of irregularity in size (megalo-
cytes and microcytos) and shape of the rod corpuscles (poikilocytosis) ; nucleated rod
corpuscles (megalo blasts and normoblasts) are present, {d) Lcucocytosis is not
present ; leucopenia may be extreme.

The Diagnosis is basod on a consideration of the symptoms, tha age and sex of

408 ] PERNICIOUS ANEMIA 563

the patient, and the blood changes — viz., a marked alteration and diminution in the
red corpuscles without diminution in the hsBmoglobin value of each cell — the con-
verse of chlorosis. Although this condition of the blood is most often met with in
association with pernicious anasmia, it must be remembered that it may also occur in
other haBmolytic anaBmias {e,g., benzene poisoning). The diagnosis from severe
secondary ansemias should not be difficult when the symptoms above described as
peculiar to pernicious anaemia are present.

Prognosis. — The disease is slow but progressive, and almost invariably fatal. Pro-
gress may be estimated by examining the blood from time to time. The main com-
plications are visceral haemorrhages, cerebral or spinal haemorrhage, and degeneration
in the spinal cord, chiefly affecting the posterior columns. Headache, nervousness,
and prostration are fairly constant, but the intellect is usually clear to the end ;
sometimes convulsions and coma occur. As recovery from one attack is almost always
followed by a relapse it is important to take care that in the intervals between the
attacks treatment puts the patient in good condition. Then the rolapses become
less severe and finally cease. Each attack may deprive the patient of half to three-
quarters of the blood in his body ; this is not fatal if at the beginning of each rolapse
the patient has a normal amount of blood.

Etiology. — Pernicious anaemia chiefly attacks males from twenty-five to forty-five,
occasionally women of the same age ; it is very rare in the young. It comes on
insidiously, without apparent cause. Hunter^ believes the disease is due to a gastro-
intestinal infection, with absorption of toxins, which destroy the red corpuscles
(haemolysis), and thus give rise to deposition of iron in the liver, urobilinuria, anaemia,
and other symptoms. It is necessary to say something about the connection of oral
sepsis with this disc-ase, as this is very generally misunderstood. The disease is
probably due to a specific micro-oiganism and the frequent association of a sore
tongue (not of oral sepsis) with its onset, and the almost invariable presence of atrophy
of the alimentary mucous membranes suggest that the site of the invasion is in these
positions. It is not disputed that great destruction of blood follows the onset of the
disease ; to this the blood-forming oi^ns respond by groat increase of activity. Now
the presence of any septic focus from which the products of the common pyogenic
organisms can be absorbed is a serious hindrance to thitt activity, because these pro-
ducts exercise a depressing influence on the blood-forming organs, leading to varying
degrees of atrophic changes. Such a focus associated only too often with this as with
many other diseases, is to be foimd in the mouth, either in the form of dental caries
or of pyorrhoea alveolaris.

TreaimerU. — Complete rest in bed is necessary. In order to give the blood-forming
oi^ns every assistance in their endeavour to make up for the blood destruction it is
of the first importance to remove all septic foci. For this reason also it is important
to remove not only oral sepsis but sepsis wherever found. We have no known method
of reaching or destroying the specific organism which is conjectured to cause the
disease, but by improving the power of resistance of the body, especially between the
attacks, much may be done (c/. Prognosis). The diet should be nutritious and ren-
dered digestible. The stomach must not be overloaded. Arsenic has a greater control
over the disease than any other drug, but it has often been noted to be of more use in
the primary attack than during a relapse ; the dose should be gradually increased
until a drachm of Fowler's solution is being given daily. It may be administered
hypodermically as the cacodylate of soda (^ to I grain), or in the form of atoxyl
(} grain). Naphthol, salol, and other intestinal antiseptics have been used with
advantage. Red marrow, transfusion of blood, oxygen inhalations, and subcutaneous
injections of antistreptococcic serum have also been tried, and have in some oases
coincided with marked improvement.

Aplastic AnsBmia is a disease in which the bone marrow loses its power of forming
blood corpuscles. This is apparently due to the action of a toxin which some have
supposed to be similar to that which causes pernicious anaemia. The symptoms are
those of a profound toxaemia. There is an especial liability to haemorrhages and a
marked stomatitis. The blood shows an advanced degree of ansemia which differs
from that seen in any other condition by the absence of regenerative forms, including

1 Dr. William Hunter ; the Lawc^J, 1901, vol. i., pp. 473. 930, and 1903, vol. i., p. 283.

6«4 GENERAL DEBILITY, PALLOIt, EMACIATION [ § 404

megalocytes, polychromatophilio and granular red cells. The decrease in leucocytes
leads to a relative lymphocytosis ; the lymphocytes may reach as many as 95 per cont.
of the total white blood corpuscles. The diagnosis can only be made by a careful
examination of the blood. The prognosis is uniformly bad, and the disease is rapidly
fatal.

The patient is pale, but the ancBtnia does not quite conform to the preceding
types, and is not readily amenable to treatment by iron. The disease is
probably some latent constitutional condition (syphilis, plumbism,
tubercle, or carciaoma), or some latent visceral disease.

§ 404. III. Syphilis (Sjoionym : Hmiterian or Constitutional Syphilis)
is a constitutional malady, due to a microbic infection, which starts as a
superficial ulcer (chancre) at the seat of inoculation, runs a prolonged and
indefinite course, is liable to break out anew during the whole lifetime of
the patient without fresh infection, even after many years of quiescence,
and in its later stages produces granulomatous deposits in various parts
of the body, particularly in the skin and nervous system.

Symptoms, — Syphilis leads to a degree of pallor which may simulate
chlorosis or other forms of ansBmia very closely. When no history of
primary syphilis is obtainable, and no physical signs can be discovered,
the diagnosis from other forms of anaemia may be difficult. For the sake
of convenience, the symptoms of syphilis are divided into three stages,
but it must not be forgotten that their mode of appearance is extremely
variable, and that the three stages may even appear simultaneously in
certain patients. Primary Stage. — The period of incubation generally
lasts about three weeks, but it may vary from ten to forty-six days. The
initial manifestation appears as a superficial ulcer (the hard or Himterian
chancre) at the site of inoculation. It is usually single, and occurs most
commonly on the prepuce or glans penis in the male, and the labiae and
nymphse in the female. It originates as a flat, elevated, painless papule,
which slowly enlarges, and may desquamate without breaking down, or
superficial erosion or ulceration takes place with a slight serous discharge,
thus differing from the deep excavated ulcer of the " soft sore " or non-
Hunterian chancre. The underlying induration of the tissues is always
a marked feature, hence its name " hard sore." The lesion after a time
cicatrises, and usually leaves behind it some slight discoloration or indura-
tion, or both, which mark the site. Sometimes the primary sore is so
slight as to be overlooked, and appears to be wanting, especially in the
female. About the same time, or within one or two weeks, the associated
lymphatic glands, usually in the groin, become enlarged and hardened.
Even thus early in the disease, the red blood discs may be diminished to
3,000,000 per cubic millimetre or even less, and there is pallor and weak-
ness, conditions which iucrease if the disease is untreated. The glandular
enlargement may become generalised, and may persist for months or
years, and hardness of the lymphatic glands may thus serve as an aid to
diagnosis at any time.

The Secondary symptoms make their appearance about three weeks
after the first appearance of the chancre (four to twelve weeks after inocu-

§4041 SYPHILIS 665

lation). In typical cases a faint generalised dusky macular rash (which
may be brought out more distinctly by a warm bath) appears chiefly on
the chest and abdomen, nearly always attended by sore throat, and often
attended by malaise, pains in the limbs, anaemia, and slight pyrexia. The
rash takes about three weeks to mature and three weeks to decline. The
pyrexia, which is generally overlooked, has already been described (§ 382).
The sore throat is usually of an indolent, ill-marked kind, with whitish
secretion resembling snail tracks (§ 113). The eruptions which may appear
now and hereafter are of many different kinds — macular, papular, scaly,
pustular, tubercular, practically never eczematous or vesicular. The
characteristics of these (see also § 489) are their reddish-brown colour,
generalised or symmetrical distribution, grouping in segments of circles,
and their preference for the forehead and flexor surfaces, their poly-
morphism and absence of itching. The hair may fall out, and the nail-
beds be affected with an indolent inflammation. Moist " mucous patches,"
with a highly contagious secretion, are apt to appear at the comers of the
mouth and other mucous orifices. The diagnosis of the skin symptoms
(§ 489) and the lesions of the mucous membranes (§ 148) are dealt with
elsewhere. The eyes may become affected by iritis, choroido-retinitis,
and the bones with periostitis in which the pain is worse at night, the
nervous system and the viscera with gummata, and the joints with syno-
vitis. Any of these symptoms may crop up again and again during the
ensuing months or years.

Later Stages (so-called tertiary symptoms) and Varieties of syphilis. —
In practice it is convenient to recognise two broad varieties of syphilis.
In most cases of a benign type, adeqaatdy treated there is no recurrence of
symptoms after the second stage above described ; in short, there is no
tertiary stage. But in other cases the disease assumes a malignant type
either by reason of the intensity of the virus or the predisposition or
debilitated state of the individual, combined perhaps with inadequate
treatment in the earlier stages, and such cases are characterised by severity
of the initial symptoms and a tendency to recurrence at intervals through-
out life. It is in such cases more especially that one meets with what are
known as " tertiary " symptoms. Ma^gnant or tertiary lesions, as
exemplified, for instance, in the skin, are characterised by having a greater
and deeper infiltration, a greater proneness to suppuration, ulceration,
and scarring, and by being followed by more loss of tissue than the benign
lesions. All the same skin symptoms noted in the secondary stage may
recur, but they are more apt to be localised and asymmetrical in distribu-
tion, serpiginous in outline, lenticular or nodular in shape, and pustular or
ulcerating in character than the corresponding secondary symptoms.
Nodular or infiltrating gummatous deposits followed by scarring, and
perhaps by ulceration, may affect the mucous membranes, particularly
in the oral cavity and its diverticula, the liver and other abdominal organs,
and the cephalic and the genito-urinary organs, and lead to fibroid de-
generation, strictuie, or destruction of the proper tissues and functions of

56ft GENERAL DEBILITY, PALLOR, EMACIATION [§404

the parts. The bones are often attacked by gummatous periosteal
deposits, leading in the case of the hard palate to perforation, and in the
other flat and the long bones to the formation of "nodes." An inter-
mitting pyrexia may accompany the formation of gimimata. The arteries
may become thickened and arterioles blocked ; partly for this reason,
partly by the proneness of the virus for the nerve-tissues and meninges,
the nervous system is specially apt to be involved. But even this list
does not complete the account of this insidious, prolonged, and terribly
far-reaching disease, for it is, as mentioned in previous chapters, one of
the two causes of lardaceous disease of the liver, spleen, kidneys, and
intestines. More or less anaemia is a symptom throughout the disease,
and in untreated or malignant cases of syphilis the cachexia may some-
times be fatal, as in patients referred to on p. 404 and elsewhere.

Para- SYPHILITIC (7ra/oa = derived from) is a term applied to certain
diseases which are not due to definite syphilitic deposits or infiltrations,
but are nevertheless due to the indirect effects of the sjrphilitic poison
on the system, or to its after-effects. Thus Locomotor Ataxy and General
Paralysis of the Insane are due to the after-effects of the virus on the
muscle sense neurons;

HERBDrrARY or CoNGENirAL Syphilis. — ^We have seen how ubiquitous
the consequences of syphilis may be, but it is upon the children of such
parents that the heaviest nemesis falls. Happily, the mother very often
aborts, syphilis being one of the commonest causes of abortion, or the child
dies and decomposes within the uterus, or, being bom alive, it dies in the
first twelve or eighteen months of life of marasmus or its complications.
Thus a series of miscarriages or stillbirths, or a heavy mortality among
children in the early months of life, imply a strong probability of syphiJis
in the parent. If the child be bom alive the primary chancre is of course
wanting, but the symptoms confirm more or less to the secondary symptoms
above described. The infant is sometimes healthy at birth, but in a few
weeks it develops " snuffles," or a ham-coloured eruption on the buttocks,
fiexures, palms, or soles, and marasmus sets in and is followed (if active
treatment is not adopted) by any of the other secondary symptoms above
mentioned. The child is fretful, the cry is hoarse, and the bones are
tender, and gastro-enteritb, bronchitis, or pneumonia may complicate
matters. If the child survives the first twelve or eighteen months of life,
a long period without fresh syphilitic manifestations ensues, excepting
perhaps in the rapid decay of the temporary teeth and stunted growth of
body. About the seventh year, however, the permanent teeth appear, and
usually present the pegged shape and notched border described by Sir
Jonathan Hutchmson (Fig. 3, § 11). Again, there may be an interval of
quiescence, but about the fourteenth year of puberty, interstitial keratitis,
deafness, periostitis, or synovitis may appear, the skin, viscera, and nervous
system only rarely being affected. From this time onwards the evidences
of hereditary svphilis consist of the consequences of the previous lesions
on the general development, the skin, the mucous orifices, the malformation

§404] 87 PHI LI 8 667

of the bones, the eyes, ears, and teeth, which are summarised in
Table XXIV., pp. 568, 569.

The Diagnosis of the Hunterian chancre will be found in surgical works.
The diagnosis of syphilitic symptoms and lesions in the skin, nervous
system, liver, and other parts, will be found in the appropriate chapters
of this work. The existence of hard shotty glands as an aid to diagnosis
has already been referred to. In regard to the diagnosis of sjrphilitic
from other forms of anaemia undoubtedly mistakes may easily be made.
I remember the case of a very anaemic lad of fifteen in whom the only
other symptom besides those of anaemia was a slight rise of temperature in
the evening, which was diagnosed as one of pernicious anaemia ; after
death, however, gummatous deposits were found in the meninges in the
frontal region and elsewhere. A somewhat similar case of gumma of the
liver was reported by the late Dr. J. S. Bristowe.^ Syphilis should always
be suspected in obsciire cases of anaemia, and very often the amenability
to treatment by iodide and mercury will be a revelation. The presence
or history of an eruption should be noted, and the viscera, the bones, and
the eyes very carefully examined. Wasserman has introduced a test for
syphilis (§ 627), which is quite reliable, if correctly performed. The
practitioner should send a sample of the blood to a well-equipped labora-
tory, as the diagnosis of syphilis is of the highest importance to the indi-
vidual and to the community.

Prognosis, — Syphilis is never fatal (except, perhaps, in the case of the
foetus) by the intenl^ity of its toxaemia, like small-pox or scarlatina ; but
in infancy it may cause a fatal marasmus. In adults it only kills, usually
after a life of invalidism, by its complications or by involving some vital
part. Benign cases of the disease adequately treated, if the patient lives
a temperate, hygienic life, may give no after trouble, and many such
persons live to old age and have perfectly healthy children. Nevertheless,
it behoves even these patients to be constantly on their guard, for once
syphilitic means that they are always liable to the possibility of recurrence
even to the end of their days. Malignant types of the disease are sure to
recur, and to require active treatment on and off throughout life. The
severity and duration of an attack of syphilis are influenced by a number
of circumstances, some of which are hard to gauge. The habits and mode
of life (especially as regards intemperance), age, occupation, exposure,
privation, pre-existing disease (especially tuberculosis and renal disease),
all doubtless influence the course of the malady. The disease is often
said to prevail in a particularly virulent form in some naval and
military stations. But of all factors, the one which influences the prognosis
of sjrphilis more than anything else is adequate and continuous treatment
during the earlier phases of the malady.

^ Clinical Soc. Trans., vol. xix., p. 240

668 GENERAL DEBILITY. PALLOR, EMACIATION [ {

Table XXTV. — ^Hereditary Syphilis.^

A. INFANTILE MANIFESTATIONS (three weeks to three months).

L Blay be bom quite healthy. Then symptoms resembling aoqoired secondary
syphilis appear — B3rmmetrical, transitory, etc.

n. Mnoous Membranes {^^ J^^^ around anus or mouth.
III. Marasmus, leading to '* senfle aspect " ; very marked wasting, often fatal.

aj^ I Always symmetrical, transitory, ham-coloured; on but-

IV Skin -I PuB^ar i *^^ becaus6 of urine and fsBces ; in flexures because of
Bull I P^^pi'^^o'^ Patches of peeling erythema about &oe,

Polj^rphioj »•*«•. ""eok. eto-
V. Iritis.

VI. Definite Periostitis — ^Tenderness of bones and ** rheumatic ** pains, epiphyseal
abscesses, or caries of long bones. Skull — ^thinning in one place, thickening
in another. Skeletal deformities and nodes.

B. ADOLESCENT MANIFESTATIONS (commencing about puberty).

Which come on after an interval of quiescence of some years, if the child survive tho

first year of life.

I. Nebular Keratitis — ^first one cornea, then the other appears like ground-g^ass —
between tenth and twentieth year. Ultimately quite clears up under treat-
ment (Fig. 3).

II. Deafness — ^between puberty and twenty-third year — comes on with noises in
ears, but without pain or otorrhoea — ^terminates in recovery or complete
incurable deafness.

III. Periostitis of long bones (rarely skull) — ^generally causes overgrowth, sometimes

bending, or nodes, occasionally suppuration.

IV. S3movitis (painless) — ^knees or other large joints.

V. Skin, viscera, and nervous system rarely affected at this stage.

C. LATE MANIFESTATIONS (from fifteen years upwards).

NoTK. — ^All of these, being the results of infantile syphilitic inflammations, are
absent if syphilitic manifestations have been previously wanting.

Effe!^^*^^^^'^ i ^^^^^^^"^^ of development, of growth, of dentition, of the
" \ catamenia.

8kin — ^Peribuccal cicatrices radiating from the mouth ; Patriot's
cicatrices.
II. Tegumentary J Eruptions (very rare) — Lupoid ulceration, gradually spreading,
System, \ may appear.

Mucous membranes — Cicatrices of the throat, palate, and round
the mouth. Hole in palate, etc.

Cranial malformations — ^prominent frontal eminences, natiform
cranium, asymmetry, hydrocephalus.

N<ual malformations — " Duck-nose," depressed septum, " opera-
glass nose."

Tibial deformities — " Sword-blade " tibia ; or curving with
shortening ; or increased length.

Joint lesions — Qironic painless effusions, and distorting arthro-
pathies.

^ This table is after Foumier, modified.

III. Osseous
System,

Ir Ooulai malformatiom.
1. Eye '. The remoants of intorBtitial keratitis {strin in ooniea),
I iritia, or choroid*! atrophy.

2. Bar CHoatrioea of thn tympaanm, doafnsgs.
{ Underhung or dUpl&oed jawt, irregnlaritiefl or aboenos
3 Teeth] of tee*''-

I Dental dyitrophiM — miorodontum, amorphinn,
[ " pegged teeth " of HuUhinson (Fig. 3).

T. FamSy f Miaoarriagea and itill'births io serieB.

Hiatory. I He»Ty mortality among children in flnt three monUu of life.

Etiology. — The specific microbe has now been identified as a feebly
staining spirochsete, to which the name Spirochteia 'paUida — Schaudinn
(Treponema PaUidwm) has been given. It can be obtamed not only from
the primary soie, but in abundance from condylomata, and also
from the viscera in secondary, tertiary, and congenital syphilis; The

Fig. 117.— 8nR0OH«lA PALLUii (Tbipobma Pailidph) Dt Syphilis, mapilfled about Mo
dlanutan. niiulntlaa lent by the ooortesy o[ Culonel W, B. Lelihnun, R.A.U.G. Tha
ocganlim li ol > iplnl 'onn like a loni corlocrew. Tha wavy organlim on the Inft ii tli«

oi^anism is a corksciew-like spirillum, having from eight to twelve curves,
one end of which is filamentous, the other thicker and more deeply
staining. It is differentiated from a commonly occurring spirillum, the
SpinUwn rejringent, in that the latter has fewer and less delicate curves,
stains equaUy deeply at both ends, and has no thickening at one end.

Syphilis resembles the specific fevers in having a period of incubation
followed by a fairly characteristic eruption, and in the fact that one attack,
renders a person immune to a second attack, with very rare exceptions.
It differs from other specific fevers in the extreme length of its course,
which may last many years, in the long intervals which may separate its
yariouB manifestations, and above all in its curious liability to nour

570 GENERAL DEBILITY, PALLOR, EMACIATION [§404

without fresh infection. Inoculation can only take place through an
abrasion of the skin or mucous membrane, and may occur in three ways :
(a) Usually it is by direct contact with an infected person, generally during
sexual intercourse, but in some cases (e.g., in doctors and mid wives) as the
result of examining diseased persons, by suckling (as in wet nurses),
kissing, etc. ; (6) occasionally by the use of contaminated articles — e.g.y
spoons, cups, pipes, towels, surgical instruments, or (1) the seat of a w.c.
In the first two stages the blood and the moist exudations of all the lesions
are certainly corUagious. In the later stages some difference of opinion
exists as to the contagiousness of the blood and secretions. My own
experience is that all moist lesions in all stages (and therefore the blood
also) are contagious, and I well remember a patient of mine who had
contracted the disease thirty- three years before, and who conveyed the
disease to his sister by kissing, he having at the time only a small fissure
at the angle of his mouth. In regard to marriage, I see no reason to
modify the rule about to be stated, however old-standing the disease may
be. The use of human vaccine lymph, even when free from blood, for
vaccination purposes from arm to arm, was undoubtedly the occasional
means of propagating syphilis, but the frequency of the occurrence was
certainly exaggerated, (c) To the offspring syphilis may be conveyed by
hereditary transmission of the virus from either parent. If, as frequently
happens, the mother becomes infected shortly before she becomes pregnant,
or during the early months of pregnancy, the child seldom escapes the
disease ; if after the seventh month, however, the child may be healthy.
It is said that the child may be infected from the father, and that the
mother may nevertheless escape ; but this is extremely doubtful, for under
these circumstances the mother never contracts the disease from her child
after its birth (Coolies' law). The date when marriage is permissible is a
most important one. It should under no circumstances be sanctioned
within two fuU years after infection, even in the mildest case. Subse-
quently, if the patient has he^en free from any syphilitic symptoms for at
least twelve months (Jonathan Hutchinson), and has been tmdergoing
antisyphUitic treatment during that time, there is every prospect that the
offspring will be healthy. It is essential to insist on this interval of
quiescence as a minimum, combined with this period of treatment, before
sanctioning marriage or possible conception.

Syphilis has, there is little doubt, prevailed from very ancient times,
and has occasionally occurred in the form of widespread and severe
epidemics, particularly when introduced into previously healthy com-
munities. Individuals of all races and ages are subject to it. Metchnikofif
and Roux and Neisser have succeeded in inoculating apes with syphilitic
virus and reproducing the disease in them ; the anthropoids are more
readily infected, and show more characteristic lesions than the lower apes.
Extremes of temperature seem to intensify its virulence. Tuberculous
and otherwise debilitated subjects usually incur syphilis in a severe and
malignant type.

§404] SYPHILIS 671

Treatment, — Fortunately, in mercury and iodide of potassium we have
efficient remedies for controlling this serious and far-reaching disease.
The most effectual remedy in the earlier stages is mercury, which should be
given continuously for at least eighteen months, whether symptoms be
present or not (Mr. Hutchinson gives eighteen months, Dr. W. Osier two
years), and subsequently, if symptoms are still present, until at least
three months after all evidences of the disease have ceased. It may be
given by mouth, by inunction or fumigation, and by hypodermic injections
into the muscles or veins. The precautions to be observed in all cases, in
addition to the duration of the treatment just mentioned, are : (i.) The
mercury must be gradually increased until the gums become tender, then
regulated until toleration is established. It is well to get rid of decayed
teeth at the very outset, and a mouth-wash of potassium chlorate and
weak carbolic acid may be necessary, (ii.) The patient should be seen
once or twice a week, so as to watch for salivation, diarrhoea, gastric
disturbances, and to regulate the treatment. If the mercury be tem-
porarily stopped, 5 grains of iodide of potassium should be given thrice daily.
Debilitated subjects and subjects of renal or visceral disease require
smaller doses and extra caution, (iii.) The patient should absolutely avoid
alcohol and tobacco while imder treatment, and take plenty of milk and
light food. The primary sore, according to Neisser, should always be
excised, although the virus may be demonstrated in the internal organs of
apes before the sore appears. This is a further argument for the earliest
active treatment of the disease both locally and constitutionally. The
open-air treatment, as for tuberculosis, is given at Aix-Ia-Chapelle. Sea
air and sea voyages are specially beneficial.

Mercury is ordinarily administered by the mouth, liquor hydrargyri
perchlor. (with or without potassiimi iodide) being given thrice daily
after meals, gradually increased ; or hyd. v. cret. gr. i. or ii., or pil. hydrar-
gyri gr. i. or ii. may be given with opium, gr. ^q, twice daily. In private
practice a convenient way to give mercury is by means of a pill of hydrargyri
iodidi viridi, gr. J to 1, with opii, gr. J to J, twice daily. Sarsaparilla and
guaiacum, when added to medicines containing mercury or iodide, appear
to increase their effects in some cases. The inunction of ung. hydrargyri is
another method ; a piece the size of a Barcelona nut, diluted with an equal
amount of lanoline, should be well rubbed into the abdomen or limbs
every night. Inimction, if properly performed, is one of the best methods
of treatment ; but it is rarely carried out efficiently in this country. In
infancy the favourite methods are the administration of hyd. c. cret.,
gr. i. or ii., once or twice daily, or the wearing of a broad flannel bandage
on which ung. hydrargyri or mercury oleate is spread daily. For adults
a cleanly method is the mercurial vapour-bath (F. 4) given daily at first.

The intramuscular injection of mercury — which is clean, convenient,
and does not upset the stomach — dates from the time of John Hunter, and
has come into vogue again during the last few years, many different pre-
parations having been used. I have been well content with a solution of

572 GENERAL DEBILITY, PALLOR, EMACIATION [§404

perchloride of mercury (F. 24), to which 1 or 2 per cent, of cocaine may be
added to prevent pain. A sterilisable hjrpodermic syringe is used, the
needle being made of platino-jridium (which resists the action of the
mercury) and being of rather larger bore than ordinary hypodermic
needles. The skin and the hypodermic needle having been rendered
aseptic, the solution is injected into the substance of a muscle, preferably
the muscle of the buttock. Start with a small dose, about yV ^ t grain
daily, or every other day, until the gums become affected ; gradually
increase the dose, and then administer about J grain once or twice a week,
or every second week, according to the state of the gums. Some prefer
the succinimide (F. 24), peptonate, cyanate, cyanide or other soluble salt
of mercury, and some recommend a solution of biniodide in oil. The
insoluble preparations — calomel, metallic mercury, or salicylate of mercury
suspended or emulsified in paraffin and injected by means of special
syringe — have been largely used in France and Germany,^ but I have
found the soluble salts to be more convenient, more rapid in their action,
and more exact in their dosage. L'huile grise (mercury suspended in oil)
is sometimes cumulative in its effects. Syphilis has been treated by the
injection of serum derived by a cantharides plaster from patients with
tertiary symptoms; 10 to 40 c.cm. were injected every third or
fourth day for one or two months. Refractory cases are said to have
improved.

It is in the later secondary and in the tertiary stages of S3rphilis and
particularly in the internal manifestations, that potassiimfi iodide finds
its chief use, and in a large proportion of these cases this alone will
promote absorption, if given in large enough doses. My belief is that
the doses generally given are not large enough, because I have known
many cases which fail with 5 or 10 grains succeed with larger doses. My
practice is to start with 20 grains, and rapidly increase the dose to 60 grains
thrice daily after meals, followed by a glass of milk. If the patient has
running from the nose and eyes, it may often be relieved by doubling the
dose. The largest dose I have given was 90 grains thrice daily. Iodide
spots may sometimes be relieved by 3 drops of liquor arsenicalis, and as
the iodide lowers the arterial tension, spiritus ammonise aromat. or other
stimulants may be called for. If iodide of potassium disagrees, even when
followed by milk, substitute the sodium and ammonium salts. After the
sjrmptoms have disappeared the doses may be lowered, but on no accoimt
should the iodide be stopped imtil at least three months later. Mercury
may with advantage be added in bad cases or if an insufficiency of the
metal has been taken.

The recent experiments of Metchnikoff and Roux with virus, attenuated
by passage through lower apes, gives reason for hope that by this means
a vaccine may be prepared tor man.

1 Roux, Jcmr. de Med. and Ghir, Prat., May 10, 1902 ; Dr. Leredde, Medical Press,
October 29,(1902'; Max Stem, Munich Med. Woch., July 2, 1901 ; see Brit. Med, Joum.,
May 30/1903, p.' 1268.

§ 405 ] PLVMBISM 673

Dioxy-diamido-arseno-benzol (salvarsan, or " 606 *') ofteu produces remarkable
success in severe oases resisting ordinary treatment. Ehrlich introduced this remedy
in 1910, and it was hoped that with one injection the disease would be cured. Time
enough has not elapsed to prove the permanency of its effects, but present evidence
tends to show that if given early the secondary stage may be aborted. Relapses
certainly occur, even after two injections, when the drug is given in the late secondary
stage. Mercury assists its action apparently. Salvarsan may be administered intra<
muscularly — a painful procedure ; or by the vein — a dangerous method not to be
attempted except by those skilled in the technique. The patient should be put to
bed ; rigor and fever may occur a few hours after the operation, but he is usually able
to go about in twenty-four hours. When the patient is not treated until the late
secondary stage, some recommend two or three injections, at weekly intervals, com-
bined with a course of mercurial injections. The drug must not be used where arterial,
nerve, or kidney disease is present, lest blindness or some fatal accident ensue. ^

§ 405. IV. Plnmbism (Synonyms : Saturnism, Chronic Lead Poisoning).
— Chronic anaemia, usually associated with a number of other symptoms,
results from the slow absorption of lead into the system, due to the con-
tamination of drinking-water or to the occupation of the patient.

Symptoms. — (1) The anaemia is very marked ; the red corpuscles may be
reduced to 50 per cent. The pale, pasty appearance of house-painters is
well known. The anaemia of lead, as in the two preceding causes, is not
very amenable to iron. (2) The gums, with but very few exceptions,
show the so-called " blue line," a peculiar livid line on the gums close to
the teeth. It is due to the formation of lead sulphide. A few medicinal
doses of lead, copper, and other metals may produce it. Sir Thomas
Oliver^ says the true blue line is incapable of removal by medicinal treat-
ment imder from eight to twelve weeks. (3) Very obstinate constipation
is usual in the subjects of chronic lead poisoning, and is sooner or later
associated with (4) severe intestinal colic (§ 172). This colic is very apt
to recur, and its recurrence is an aid to its diagnosis. (5) Lead is usually
found in the urine, and chronic plumbism is frequently associated with
slight albuminuria. Ultimately chronic Bright's disease supervenes. The
arterial tension is high, and arterial sclerosis supervenes relatively early in
life. (6) Lead has a special tendency to attack the peripheral motor nerves.
It has a special proclivity for the musculo-spiral nerve, and thus the '
typical lead palsy is a " wrist drop " due to paralysis of the extensor
muscles of the forearm. It is important to note that the supinator longus
generally escapes, and therefore supination is preserved. Both limbs are
invariably afiected, though one side may be worse than the other. The
muscles rapidly waste, and present a typical reaction of degeneration.
Other recognised types of paralysis are the brachial (or scapulo-humeral),
the Aran-Duchenne (resembling chronic anterior poliomyelitis), the
peroneal, and the adductor laryngeal. Sometimes all the limbs are
affected, so that a complete generalised paralyBis, including perhaps the
diaphragm, may supervene. Muscular tremor is not very common in the
lead poisoning due to drinking-water, but is met with sometimes in the

^ Discussion, Brit. Med. Assoc, Brit. Med. Joum., September 23, 1911; and
Sequiera, the Lancef, January 20, 1912.
a " Dangerous Trades," London, 1902.

674 GENERAL DEBILITY, PALLOR, EMACIATION [}405

pre-paralytic stage ; it is, however, very usual when the lead is introduced
into the system by inhalation — e.g., among lead miners and glass-blowers.
Optic neuritis, neuro-retinitis, amaurosis, and amblyopia are met with.
Cerebral symptoms (saturnine encephalopathy) are met with, such as
acute mania, convulsions, coma, and occasionally insanity.

The Diagnosis of lead poisoning is not difficult when once our suspicions
are aroused. Each of the above s^Tnptoms is fairly 'characteristic, and
when all are met with together there can be no doubt. In doubtful cases
of ansemic pallor the urine should be carefully examined for lead. The
" blue line " is very characteristic. Presence of basophil granulation of
the red corpuscles usually precedes the early symptoms.

Prognosis, — The prospect of recovery varies with the duration of the
disease, the severity of the symptoms, their amenability to treatment, and
the condition of the kidneys. Slight palsies may be completely restored,
but when there is extreme muscular atrophy and persistent absence of
faradic reaction recovery is rare.

Etiology. — (1) Numerous occupations afford opportunities for the intro-
duction of the poison either into the alimentary canal or by inhalation
into the lungs, such as painters, lead workers, plumbers, pewterers, glazed
card makers, pottery glaziers, file cutters, chromic dye workers, enamellers,
glass workers, lead foil makers, shoe finishers, bleachers of Brussels lace,
printers' compositors, and lead miners. (2) The disease may occur in
epidemics owing to the consimiption of contaminated water which has
been stored in leaden cisterns, or has passed through leaden pipes. A
specially soft water is apt to dissolve a certain amount of lead carbonate
usually found inside leaden pipes. In other epidemics, such €ts that of
Newcastle in 1900, the water has been found to be slightly acid near its
source. (3) Various articles of food or drink are apt to become con-
taminated when stored in lead, lead-glazed, or pewter vessels, such as
tinned provisions, beer, cider, or wines. Cases still occur in men who have
drunk the beer first drawn off in the morning which has lain some hours
in a pewter or leaden pipe, (i) Rarer causes are the sleeping in newly-
painted rooms, and occasionally in susceptible persons the external applica-
tion of a lead lotion may produce poisoning. The internal administration
of lead as an abortifacient is said to be common in some Midland towns
(Ransom). Any age or sex may be afl^ected, but women appear to be more
susceptible than men. A first attack may not occur until after exposure
for many years. Alcohol predisposes.

Treatment. — The first indication is the avoidance of the cause, and
those who are exposed to the poison by reason of their occupation should
observe the greatest personal cleanliness. The face, hands, and teeth
should be cleansed before meals. The ventilation of the workroom should
be supervised, and a respirator worn if the air contain much dust. Sir
Thomas Oliver has a poor opinion of the prophylactic value of sulphuric
acid lemonade, inasmuch as the sulphate of lead is hardly less soluble
than the carbonate. Fruits and alcohols should be avoided. Saline

§ 405 ] CA USES OF PALLOR 675

aperients and small doses of iodide of potassium should be administered,
but the latter should be increased with caution, so as to avoid flooding the
blood with a soluble lead salt. The treatment of the constipation, colic,
paralytic and other nervous lesions will be found in their appropriate
places.

V. Incipient Tabercolosis is generally attended by anaemia, pallor,
weakness, and loss of flesh. The anaemia is often very marked, and if a
young anaemic patient is not amenable to treatment by iron latent tubercu-
losis should always be suspected (Trousseau). The disease may be
entirely latent in the sense of being unattended by any physical signs in
the lungs or elsewhere. It is useful to remember that a tuberculous process,
no matter where it is situated, is always attended by pyrexia of an inter-
mittent type, though this is apt to be overlooked. Inquiry should there-
fore be made for sweatings or '* chills," careful temperature readings should
be procured, and the sputum and urine should be examined for the bacillus.
The early diagnosis of tubercle in the lungs, meninges, kidneys, peritoneum,
and other parts has been given in their appropriate places. Early spinal
caries may also be overlooked, and the only symptoms present may be
slight pain in the hypogastrium. Certain tests are now employed as
methods of diagnosis in tuberculosis, and are described in § 94.

YI. Incipient or Lateut Carcinoma and sarcoma are also attended
by pallor, weakness, and emaciation ; they form the essential parts of
cancerous cachexia. The. pallor does not yield to iron. Emaciation is,
however, usually the most constant and most prominent feature, and
therefore malignant disease will be considered fully under the symptom
(§ 415). 1 have twice mistaken cases of scirrhus of the pylorus for
examples of primary anaemia.^ They were cases in which the pyloric end
of the stomach was drawn up under the liver, and therefore local signs of
the disease entirely escaped detection during life. The diagnosis is all
the more difficult when it occurs, as it did in these cases, without vomiting,
and in comparatively young women, aged twenty -eight and thirty-five
respectively. There may be haemic murmurs, and on rare occasions inter-
mitting pyrexia. Nowadays an expert opinion on the blood would
almost certainly prevent such an error. Another case of anaemia which
came imder my notice for a severe persistent neuralgia of the third sacral
nerve, lasting many months, eventually proved to be carcinoma of the
prostate. Repeated careful examination should be made of all the
abdominal and pelvic organs and of the blood.

VII. Dsrspepsia, Constipation, Colitis, and various other disorders of the
alimentary canal frequently come under our notice for pallor. Indeed,
dyspepsia and confinement indoors are perhaps the commonest causes of
pallor among hospital out-patients, and it must not be forgotten that
decaying teeth associated with pyorrhoea alveolaris may, as Dr. William
Hunter^ has shown, be a potent cause of intense anaemia. Deficient food,

1 ClinicalJoumal, February 13. 1896, vol. v., p. 261.

2 Tho Lancet, 1901 and 1902.

576 GENERAL DEBILITY, PALLOR, EMACIATION [ f 406

and particularly deficient nitrogenous food, may also act in a lesser degree.
In dyspeptics the pallor is of a peculiar kind, in which the skin loses its
lustre and may even be scurfy, and there are dark rings imder the eyes.
In colitis and other intestinal afiections the same may be observed, and
it is wonderful what an improvement in the patient's appearance is made
after a course of treatment by salicylate of bismuth, naphthol, or other
intestinal antiseptics, combined with purgatives. Many cases in this
group are auto-toxsemias.

VIII. Aortio Valvular Disease often presents a sallowness which may be
mistaken for the pallor of primary anaemia. The patient is usually an
adult at or past middle life. In aortic regurgitation the cardiac murmur
and the pulse (§ 47) are sufl&ciently characteristic for the detection of the
disease on examination. But in aortic obstruction the most experienced
auscultators may fail to detect or may misinterpret the signs of the lesion.

IX. Chronio Renal Disease is sometimes accompanied by a pallor which
may readily be mistaken for primary anaemia. This is especially the case
in chronic parenchymatous nephritis, which is apt to alEect young people.
The pallor, however, is of an ivory whiteness, is usuaUy accompanied by a
certain amount of dropsy, and the urine reveals a definite amount of
albumen and tube casts. Chronic interstitial nephritis is usually met with
in older people ; it is generally attended by sallowness, but is mentioned
below under progressive asthenia, which is its more constant and striking
symptom.

X. Cirrhosis of the Liver may be attended by an anaemic pallor ; but
it is usually attended also by dilatation of the venous capillaries in the
face, which are very characteristic. The signs and symptoms of this
disease may be very obscure.

Certain other secondary ancemias are readily detected by their history — viz., Hjemor*
RUAQE, or long-continued drain on the system ; Chronic Suppuration, or other septic
processes ; Rheumatic and other febrile conditions.

XI. Ansemia may be due to hsBmorrhage — profuse and sudden, or small and
frequent ; hyperlactation, profuse chronic diarrhoea, and other debilitating conditions.
Such cases are generally discoverable by a history of the cause, such as monorrhagia,
post-partum or antc-partum haemorrhage, bleeding piles, melsena, recurrent epistaxis,
h^ematemesis, haemoptysis, hsematuria, etc. The treatment resolves itself into attack-
ing the cause. But in severe cases of post-hsemorrhagic and other forms of intense
ansemia, and whenever collapse is present, transfusion or infusion may be called for.

§ 406. Infusion of Saline Solution ^ may be indicated in the presence of shock,
collapse, or intense ansemia, arising in three groups of conditions : (1) Acute haemor-
rhage, resulting from abortion, post-partum, and other causes of uterine hssmonhage,
gastric or intestinal ulceration, operations attended by profuse bleeding, or internal
hsemorrhage after abdominal injuries. (2) Collapse consequent upon surgical opera-
tions, cholera, or severe diarrhoea due to any cause. (3) Blood poisoning — e,g., in
ursemia, puerperal eclampsia, diabetic coma, or poisoning by carbolic acid, stryohnine,
or phosphorus. Infusion of saline solution can be much more rapidly and easily per-
formed, and skilled assistance is not necessary. As a mere diluent or to make up the
volume of the blood it is of great value, and has almost entirely superseded transfusion.
In oases of blood poisoning (Group 3 above) venesection should be performed to

^ Transfusion of Hood from one j>er8on to another is at the present time not so much
employed as in the past. It is described in surgical textbooks.

§ 407 ] INFUSION OF SALINE SOLUTION 577

eliminate the poison before the saline solution is administered. Sodium chloride
(a neutral salt) is used to bring the specific gravity of the fluid to be injected up to that
of the blood plasma. The normal saline solution (0*75 per cent.) is prepared very
readily by dissolving 1 drachm (or to be exact 66 grains) of common salt in a pint of
boiled water. Hypertonic saline solutions are giving good results in cholera
($ 220). The infusion may be made (1) into a vein; (2) into the subcutaneous
cellular tissue of the thighs, auterior abdominal wall, below the clavicle, or mammas ;
or (3) into the rectum. For injecting the solution into the subcutaneous tissue an
ordinary exploring needle connected to a rubber tube 5 to 7 feet long, with a glass funnel
or a douche-can — all rendered aseptic — and a thermometer, complete the necessary
apparatus. The needle is inserted after cleansing the skin, and the operator standing
on a chair pours the solution (at a temperature of 99^ or 100° F.) from a height of
3 to 6 feet above the needle slowly into the funnel. Three to six oimces may be injected
at intervals of ten to fifteen minutes. If necessary, more than one puncture may be
made. Usually i to 2 pint is sufficient, but 2 to 3 pints may be needed. The puncture
must afterwards be sealed with collodion. The danger of abscess or sloughing is very
slight in young or middle-aged persons if the infusion be slowly done, and not too much
in one place, and if aseptic precautions are thoroughly carried out. To inject saline
solution into the rectum a similar apparatus with a rectal tube is employed. This
method is simple, yet often of great service, particularly in the collapse after operations.

XII. Ohronic Suppuration (with or without amyloid disease) and other septic pro-
cesses and causes of a prolonged drain on the albuminous materials of the blood are
potent sources of ansemia. Prolonged lactation also may act in this way. Mention
of the leucooytosis, which is characteristic of suppuration or abscess, has already been
made (§ 398), but in addition the haemoglobin and the red cells may be deficient.

XTTT. Pof t-febrile Anasmia, associated nearly always with weakness and emaciation,
may ensue after rheumatic fever, enteric fever, varicella, malaria, and indeed after
any of the acute specific fevers.

XIV. Finally, in various conditions referred to in Group II. below

(Emaciation), or Group III. (Debility), pallor maybe the symptom which

first attracts our notice, for these three important symptoms are so often

associated. Early myxoedema (§ 419), is one of these, and the puffiness

of the eyes, the failing memory, loss of hair, and bodily weakness may for

a time escape observation, or be attributed to other causes. Myelopathic

albumosuria also may first come under notice for ansemia.

Rarer Causes of Ancemia,

The patierU is pale and ancemic ; there is enlargement of the spleen,
or the LYMPHATIC GLANDS, or both, and characteristic changes m the
BLOOD. The disease is probably Leukemia, Hodgkin's Disease, Splenic
Anemia, or a Sequela of Malaria.

§ 407. I* Lenkasmia or Leuoooythasmia is a comparatively rare disease characterised
by progressive ansemia, a large and persistent increase of white corpuscles, a slight
diminution of the red cells, accompanied by enlargement of the spleen. There are two
varieties of the disease : (a) The spteno-meduUary or myelogenous type, and (6) lym-
phatic louksemia. The former is due to an apparently purposeless overgrowth of the
bono marrow, the latter to a similar activity of the lymphatic tissues. In the first
variety the circulating blood is found to contain excess of cells of myeloid origin ; in
the latter an excess of lymphocytes. In many of their clinical manifestations they
are very similar. Either variety may occur as a chronic or as an acute disease.

Spleno-Mbdullaby Lettksmia — Symptoms, — ^These are often indefinite in the
early stages. The patient may only complain of general weakness and debility and
tho pallor may not be very marked imtil late in the disease. In other cases the
symptom first complained of may be epistaxis, vague pains, dyspncsa, enlargement

'61

678 GENERAL DEBILITY, PALLOR, EMACIATtOI^ i$40lf

of the abdomen, or cerebral Bymptoms. As the disease develops the symptoms are
seen to fall into two groups — ^those due to the blood condition and the resulting
toxaemia, and pressure symptoms due to the presence of nodules of new growth in
various situations. In the first group the most important are cachexia, weakness,
and haemorrhages. Pyrexia of an irreg^ar type is present in three-fourths of the
cases. The urine shows an excess of uric acid. In the second group come enlarge-
ment of the spleen, and pain and discomfort due to this or to perisplenitis ; slight
•or sometimes enormous enlargement of the liver, enlargement of lymphatic glands,
infiltration of the skin, gastro-intestinal disturbance, dysphagia, dyspnoea, and ascites.
The splenic enlai^ment may be enormous, extending into the pelvis ; sometimes
the patient comes first complaining of abdominal swelling. Acvie spleno-medullary
leukaemia resembles acute lymphatic leukaemia (see below) in its clinical course. It
is especially apt to be associated with numerous tumours in various parts of the body,
due to the lighting up into new activity of remnants of the marrow tissues of the
foetus. The blood cells are usually more primitive than is the case in the chronic
form, and may with difficulty be differentiated from " lai^ lymphocytes." There
are, however, a few eosinophil myelocytes, which are not foimd in the lymphatic form.
Etiology. — ^This disease occurs between the ages of twenty and fifty, but oases are
also reported outside these limits, and some authorities speak of congenital cases. It
affects men moro often than women. Nothing is known as to the cause.

Dicignodie. — ^The most striking point is enlargement of the spleen ; this will often
suggest the presence of the disease, but the diagnosis ultimately rests on the con-
dition of the blood, in which are found a large excess of all colls formed in the marrow
— i.e., (i.) myelocytes of all sorts ; (ii.) nucleated red cells, and an increase also of
(iii.) the leucocytes normally found in the blood-stream — i.e., the polymorphonucleais,
mast cells and eosinophils. The leucocytosis varies between 100,000 and 500,000 or
more in average cases ; the latter figure is quite usual. Towards the close of the
disease the red colls undergo marked diminution.

Prognosis. — ^This, in the last resort, is serious, as very few cases have been known to
recover. Remissions in which the patient regains health and the blood becomes
normal may last for two or throe years, but are usually followed by recurrence.
These remissions can, as a rule, be brought about by the use of X rays. The disease
is essentially chronic, and may last ten years ; it seldom lasts less than one year.
Death may result from asthenia, or from complications such as cerebral hsemorrfaage,
other haemorrhages with much loss of blood, or severe diarrhoea.

TrecUment. — Arsenic is the only drug which seems to have at all a specific action.
It should be given in progressive doses, and when a remission has been brought about
the patient should continue to take the drug as long as the blood shows any abnor-
mality. Unfortunately, arsenic seems to lose its power after a time. The X-ray
treatment of this disease is comparatively new, but has given some very good results.
It is essential that the patient should submit to periodical blood examinations in
order that X-ray treatment may be commenced again as soon as the blood shows signs
of a recurrence.

Lymphatic Leukaemia usually occurs in an acute form.^ The spmj^oms may
be very various when the patient first comes under treatment, a frequent one being
stomatitis, due to the breaking down of small lymphoid nodules beneath the
epithelium of the gums, with subsequent infection and haemorrhage. (L) Rapidly
progressive anaemia with asthenia and haemorrhages ; (iL) enlargement of tiie spleen,
liver, kidneys, and lymphatic glands, (iii.) Tumours similar in distribution to those
seen in spleno-medullary leukaemia are more common in this form of leukaemia and
also more frequently associated with chloromatous changes, (iv.) The blood shows
excess of lymphocytes which vary considerably in their form and staining reactions
(Plato III.). The average number is about 100,000 to 200,000 per cmm. There are
nearly always a few nucleated red cells to bo found, and mitotic figures are not un-
common, although perhaps less constant than in the splcno-medullaiy form. Chronic
lymphatic leukamia resembles Hodgkin's disease in most of its features ; often the
blood condition is the only feature which differentiates the two. As a rule all groups

' Forbes and Langmead, Proc. Roy. Med. Soo., May, 1908.

408]

HODOKIN'8 DISEASE

579

of the lymphatic glands enlarge at the same time, whereas in Hodgkin's disease the
enlargement of one group usually precedes that of any other. Lymphoid growths in
the walls of the stomach may lead to dyspepsia and vomiting.

Table XXV. — The Diagnosis op Leukaemia.

Splenthmedulktry
Leutmmia.

LymphaHe
LeukiBtnia,

Hodgkin's
DitMue,

Splenic Anamia,

Spleen.

Spleen greatly in-
ereased.

Spleen moderately
increased.

Spleen slightly en-
larged In | of
the cases.

Spleen greatly en-
larged.

Lymphatie Olandt.

Not usually
enlarged.

Moderately
enlarged.

Greatly
enlarged.

Not enlarged.

Leading Blood Changee.

Leucocytosifl marked, chiefly due
to myelocytosis. Eosinophil
cells also increased. Red cells
show progressive amemia.

Leucocytosis marked, due to in-
crease of lymphocytes. Red cells
show progressive anaemia.

Slight leucocytosis in some cases
moderate anaemia.

Leucopenia ; marked aucemia.

Etiology. — Males are more frequently affoctod than females. Children are attacked
with relative frequency, but the disease has been seen at tho ago of seventy-three.

The diagnosis depends on tho finding of the characteristic blood changes.

Prognosis. — ^Tho disease is usually acute, lasting not more than six or eight months,
and it may be much more rapid. Complications are as in the spleno-medullary form.
Thrombosis is not uncommon, especially of the corpora cavernosa. The chronic
form may last two to throe years or as m%ny as ten.

Treatment. — ^This is in the main symptomatic. Arsenic is indicated, as in the
spleno-modullary variety of the disease. Great care should be taken not to cause
any abrasion of the skin, as the healing power is very defective ; gangrene has been
known to follow the application of a blister.

Ohloroma or ** green cancer " is a term applied to green leukaemic growths met
with in the periosteum of the head and face, and in other parts where leuksemio
growths may occur. It is a rare manifestation of leukaemia, somewhat similar to
lymphosarcoma in its clinical characters. The green colour may be obvious in tiie
urine.

§ 408. II. Hodgkin'i Disease (Sjmonym : Lymphadenoma) is a disease characterised
by anaemia, progressive hyperplasia of the lymphatic glands, and sometimes lymphoid
g^rowths in the liver, spleen, kidney, and other organs. There are two forms of the
glandular enlargement, soft and hard. In tho former tho glands are soft in consistence
and somewhat enlarged ; there is a proliferation of the endotholial cells, dilatation of
bloodvessels and lymph sinuses, while masses of lymphocytes crowd the lymph
sinuses, and large multinuclear cells also occur. In the hard variety, which is usually
a more advanced form, the glands are much enlargod and hard in consistence, and
there is a great increase in the fibrous tissue which takes place at the expense of the
other cells.

Symptoms. — (1) Sometimes debility and anaemia are the first symptoms, but more
frequently enlargement of tho lymphatic glands of the neck, axiilas, or groins first
attract attention. The enlargement of tho cervical or other single group of glands
may precede that of any other glands for a considerable time, even for a few years,
but usually the extension to other glands is more rapid. In chronic forms of Hodgkin's
disease the glands are hard, separate* and movable under the skin ; but in the acuter
forms the glands feci soft. For accurate diagnosis a gland should be excised under
local anaesthesia, and examined microscopically. ^ In Hodgkin's disease the glands

1 I>r. Dorothy Reed has shown that the glands show characteristic changes :
(1.) proliferation of the endotholial cells, and excess of lymphocytes filling tho lymph
sinuses ; and, later, (it) excess of fibrous tissue. ('' Johns Hopkins Hospital Reports,"
1902, vol. X., p. 133.)

580 GENERAL DEBILITY, PALLOR. EMACIATION [§409

readily beoomo the seat of secondary infeotion; henoc ^probably the variation in the
olinioal symptomb and course. (2) Pressure effects occur when the deep glands — e^g,,
in the thorax — become involved, and occasionally they are the first to enlarge. The
pressure symptoms are described in § 54. Bronzing of the skin may arise as a oon-
Boquence of pressure on the solar plexus. (3) Irregular paroxysms of intermittent
pyrexia occur at intervals of a few days or a few weeks, and these attacks may coincide
with a paroxysmal enlargement of the lymphatic glands. (4) The spleen enlaiges aa
the glands enlarge, but the enlargement is never very great ; usually the edge can
just be felt below the costal maig;in. The liver also enlarges in most cases. (6) The
blood changes are not characteristic ; they consist chiefly of diminution of the hemo-
globin and the number of red corpuscles with poikilocytosis in the later stages. (6) The
constitutional symptoms, anaemia, and languor, increase, and in the later stage may
become extreme with the concomitant symptoms of emaciation and a marked ten-
dency to hsDmorrhagos (as is usual in all profound anaemia). (7) Pruritus may be
very severe, especially if there be nodules of growth in the skin.

Diagnosis. — Clinically, Hodgkin's disease and the lymphatic variety of leukcBtnia
are alike, but an examination of the blood at once reveals the di£ference. The blood
in Uodgkin's disease shows only a diminution of the haemoglobin and the red cells,
and in the later stages only a slight degree of polynudear leucocytosis ; in leukaemia
there is always a marked and characteristic increase in the number oflympJiocytes through-
out, and usually an increase in the total number of leucocytes. Lymphosarcoma haa
been considered on the Continent to be akin to Uodgkin's disease. In lymphosarcoma
the growth, though primarily involving the lymphatic glands, invades the surrounding
tissue, and thus levoals its malignancy. The diagnosis from tubercvlous adenitis is
often difficult. Tubercle is more common at an earlier age ; the glands tend to be
matted together, and to caseate or suppurate. The tuberculin tests, if positive,
prove the proseucc of tubercle, but they cannot decide whether the morbid process
iD a given case was tuberculous at the onset. Syphilitic glandular enlargement is
preceded by the appearance of a chancre ; the glands are very hard, and tend to dis-
appear rather than to spread.

Prognosis. — Hodgkin's disease usually runs a slow chronic course, months, or even
years elapsing before extension from one group of glands to another. On the other
hand, the disease may run an acute course, all the glands enlarging within a few
months. Cases are reported to have recovered or improved or remained stationary
for a long period without special treatment, and chronic cases have entirely recovered
under treatment. In severe cases the ansemia and emaciation are marked, and death
occurs from exhaustion, or with delirium and coma. Complications such as pneu-
monia, pleural efihision, pressure on the bronchi or trachea may also cause death.
Difficulty in swallowing may arise from overgrowth of the adenoid tissue in the
pharynx or thorax.

Of the Etiology little is known. The disease usually arises in the first half of life.
Among Sir William Gowers* 100 cases 30 were under twenty years old, 34 between
twenty and forty, and 36 over forty. It is three times as frequent in men as in
women. ' An infective origin hats been susjiected. In some cases the disease has been
attributed to an attenuated tuberculous infection. In other cases a local cause of
irritation, such as nasal catarrh or a bad tooth, has led to a local enlargement of a
group of glands which was followed later by a generalised lymphadonomatous enlarge-
ment.

Treatment. — Local chronic groups of glands should be removed. Keooveries have
been reported with the use of arsenic. It should bo administered for months at a
time in gradually increasing doses until the limit of tolerance is reached. Iodides are
useless. Phosphorus should be tried if arsenic is ill borne. Tonics, cod-liver oil, and
all other moans to keep up the patient's strength are useful.

§ 409. III. Splenic Anaemia is a rare disease, the characters of which are : (I) Splenic
enlaigemont which cannot be connected with any recognised cause ; (2) absence of
any enlaigemont of the lymphatic glands ; (3) secondary ansemia ; (4) leuoopenia. or
at most no leucocytosis ; (5) an extremely prolonged course lasting years ; and (6) a
tendency to haemorrhages, especially gastro-intestinal. from time to time. Tho
patient may come under observation during the early stage of the disease when anaemia

i 410 ] SPLENIC ANJBMIA—80VRV Y 681

with its oononrrent symptomB is complained of. In some oases the splenic enlaige-
ment appears to precede the anssmia. and the patient may not seek advice until his
spleen has reached the umbilicus. In the second stage there is enlargement of the
spleen, accompanied by attacks of pain during periods of enlargement of the organ.
The spleen n this disease attains an enormous size, often as great as that which occurs
in leukaemia. The enlargement is duo to fibrosis of the organ, with atrophy of the
Malpighian bodies. As the disease progresses there is loss of strength without emacia-
tion, accompanied by gastric disturbance and a tendency to haemorrhages. Some-
times there is a moderate enlargement of the liver. Pyrexia is present during the
active stages of the disease. The blood shows a diminution of the number of the red
cells, and a greater diminution of the haemoglobin. Poikilocytosis may be present.
In the third stage of the disefkse all the symptoms are aggravated, and in a few oases
of the disease the so-called '* Banti's disease " supervenes, with fatal termination.
The name " Banti*s disease ** has been given to a group of sjrmptoms comprising
cirrhosis of the liver, jaundice, and ascites, consequent on splenic ansemia, as described
above.

The Diagnosis from most forms of secondary ancmnia is effected by the great enlarge-
ment of the spleen, and from leukcmnia by the characteristic blood changes in that
disease (§ 407). Pernicious ancsmia is rarely associated with an enlarged spleen, but
difficulty may arise when the blood changes in a severe case of splenic anaemia resemble
those of pernicious anaemia. The chief practical difficulty lies in diagnosing the disease
from cirrhosis of the liver with accompanying enlargement of the spleen. If the red
corpuscles and the haemoglobin rapidly increase under treatment by iron, it is im-
probable that the condition is due to splenic anaemia. Banti's disease may be almost
impossible to diagnose from cirrhosis of the liver unless a history including the blood
changes of previous years can be obtained. Many cases regarded during life as splenic
anaemia are found after death to be due to msceral syphilis, cirrhosis of the liver, or
thrombosis of the portal vein. In Kala-azar there is a history of residence abroad
and liver puncture reveals the parasite.

Prognosis. — ^The disease is a chronic progressive disorder. It used to be said that
death occurred in six months to two years, but it is now known that cases may live
ten, twelve or even twenty years after the commencement of the disease. Death
takes place by asthenia, occasionally by syncope or haemorrhage.

Eulogy, — ^Men are more often affected by this disease than women ; it occurs
mostly in adult life, but may occur at all ages. The cause is unknown.

The Treaimeni is symptomatic. Arsenic is the most efficacious drug. In early
stages splenectomy cures. X rays may do good.

The patient is very pale and ancemic, and there are or have been soreness
of the auifs, purpuric spots, arhd brawny indurations of the legs. The
disease is probably Scorbutus.

§410. IV. Sovrvy (Synonym : Scorbutus) is a constitutional disease due to deficiency
of fresh food, animal and vegetable, attended by extreme debility and anaemia,
sponginess of the gums, and haemorrhages. The disease is only rarely met with now,
but used to be the scourge of the British navy, until the introduction of lime-juice as
a prophylactic, which now all ships are obliged to carry.

The Symptoms start insidiously, and consist of (i.) progressive debility and anaemia,
with mental depression and heaidache, but no pyrexia. Palpitation, haemic mur-
murs, syncopal attacks, and other symptoms of anaemia develop. Pains in the back
and limbs are usually complained of early. The urine is scanty and highly acid, and
may contain albumen, (ii.) The gums become spongy, swollen, and bleed readily.
Sloughing may follow, and the teeth become loosened ; the breath is very offensive.
Constipation is usual, but diarrhosa with blood may occur later on. (iii.) A charac-
teristio eruption appears, consisting of purpuric spots and swellings of brawny con-
sistence found about the flexures of the joints, especially the popliteal space. These
swellings are due to haemorrhages into or beneath the skin ; if the former, they are
purine ; but if beneath the skin, the colour may be pale. Swellings also occur later
under the periosteum of the bones of the legs. Epistaxis often occurs, but haemor-

682 GENERAL DEBILITY, PALLOR, EMACIATION [§411

rhage from other muoouB mem branes is not common except in severe cases, (i v. ) Death
may ensue either from syncope, asthenia, or complications. Among the latter may
be mentioned sanguineous effusion into the pleura or meninges, pneumonia, and
sloughing of the skin.

Diagnosis. — The diagnosis of scurvy from other causes of purpuric eruption is
afforded by the condition of the gums, and the hard brawny swellings, which are
peculiar to scurvy, and also by the degree of prostration present. Slighter cases are,
however, very difficult to diagnose, as similar symptoms may be seen with purpura.
Rapid improvement with suitable diet favours a diagnosis of scurvy. A blood count
should be made, which would at once distinguish scurvy from the acute blood diseases,
which are also accompanied by stomatitis and hsemorrhago. Syphilitic nodes on the
tibis accompanied by cachexia should be carefully differentiated from scurvy, because
mercury is so injurious in the latter disease. In pernicious ancsmia there is a longer
history, and blood changes are present.

Prognosis, — As a rule this is good if the cause be discovered, and removed. Un-
favourable symptoms are severe dyspnoea, syncope, scanty urine, and elevations of
temperature. Convulsions, hemiplegia, and other cerebral sjrmptoms follow intra-
cranial haemorrhage. The outlook is grave when dysentery complicates the disease.
Necrosis of the jaw or other bones is rare.

Etiology. — ^The chief cause is an absence of fresh vegetable from the dietary, though
this will not produce scur\'y if fresh meat is available. It is the combination of
salted or tainted meat and the absence of fresh vegetable which leads to scurvy. It
has occurrod in well-to-do women who live on tea and bread-and-butter. It appears
that <ii^nic salts are more unstable than others, and thus potassium, for example,
if combined with an organic salt, will more readily reach the tissues and there be con-
verted into a carbonate, than if it bo taken in the form of a chloride or a phosphate,
which are more stable salts. In fruits and vegetables which have organic salts, tiiere-
fore, the mineral constituents more easily reach the tissues than in animal foods,
which have inorganic salts. Professor Axel Holst^ has shown that rabbits fed on
a scurvy-producing diet can only be kept free from scurvy if given fresh vegetable,
not if the vegetable be previously dried, even if sodium bicarbonate be added to it.
More recently he has found that certain fresh vegetables can prevent experimental
scurvy and experimental neuritis resembling beri-beri, which suggests that both
diseases result from the lack of some vital property in the food.*

Treatment consists in giving a liberal diet, with fresh vegetables, the juice of two
lemons daily, fruits, light wines, claret, tea. and cider. Scraped raw meat and milk
are good for severe cases. For the mouth give a gargle of potassium chlorate or
Condy*8 fluid, or pencil the gums with a strong solution of silver nitrate. Bismuth
and opium are needed for diarrhoea, and foods which would irritate such oomplica-
tions as dysentery should be avoided.

The palient is pale and liable to uncontrollable bleedings, /rom
jiMe or no cause. The morbid condition is probably Hemophilia.

§ 411. V. Hasmophilia is a hereditary disease characterised by a constitutional
tendency to uncontrollable hemorrhage without sufficient cause.

The Symptoms are divided into three sets : (I) Haemorrhages from mucous mem-
branes, or after some slight injury, from the skin. Nothing abnormal may be noted
in a subject of hsemophilia until he has a tooth extracted or a trifling abrasion, when
uncontrollable bleeding due to capillary oozing sets in, and lasts for hours or days.
When the bleeding occurs from a mucous surface, large blood tumours may form as
the blood coagulates. (2) Interstitial hsemorrhages occur spontaneously or after
injury in the form of petcchise or hsematomata. (3) Affections of the joints, especially
the knees and elbows, are met with, and three stages are described : (i.) Recurrent
hsemarthroscs or effusions of blood into the joints, of acute onset, sometimes attended
by pyrexia ; (ii.) reactionary synovitis ; and (iiL) cicatrisation which may lead to
permanent deformity.

1 Brit. Med. Joum.. October 31, 1908. p. 1366.

2 l^ofical Society, November, 1911.

§ 411 ] HEMOPHILIA 683

Diagnoeis. — A single severe haemorrhage does not warrant a diagnosis of haemo-
philia, but reeurrent haemorrhages with slight cause are oharacteristio. The family
history of a tendency to bleeding is important. The joint a£fections are diagnosed
by the presence or history of other signs of haemophilia.

Prognosis. — The disease usually becomes evident during the first few years of life,
and as a rule tends to be less troublesome as life advances, disappearing about thirty
or forty. Great anaemia occurs from oxcossive bleeding, and life has been lost after
trivial operations such as the extraction of a tooth or circumcision.

Etiology. — Hsemophilia occurs in families for generations. It is met with in males,
in the proportion of 13 to 1 female, but the diathesis is transmitted through the
female who herself may remain unaffected. The cause of the condition is unknown.

TreatmenL — Males in a bleeder*s family should be guarded from any injury or
operation. The daughters should not marry, for though they themselves are not
endangered by parturition, their sons will probably be bleeders, and their daughters
will pass on the same tendency in turn to their offspring. When bleeding occurs, rest
is essential, and styptics are applied. Internally adrenalin chloride, calcium chloride,
iron perohloride, and ergot have done good.

VI. Addison'i Disease, Morphinii m, and maladies mentioned in Qroups n. and III.
(below) occasionally come under our notice for anaemia.

There is pallor of the skin and the patient has been abroad. Inquiry
should be made for Malaria, Chronic Dysentery, Worms, and other
Parasites, or other Tropical Diseases.

VII. Various tropical diseases and other pyroxial conditions rarely, if ever, seen
in England, arc attended by intense anaemia.

(a) Malarial anatmia is usually accompanied by pigment changes around the eyes
and other parts of the body. The history here, of course, is our first clue to diagnosis.
The earthy pallor and the enlargement of the spleen (ague cake) are very charac-
teristic.

(b) Dengue, beri-heri, dysentery, and other fevers unknown in this country are
accompanied and followed by anaemia. In the two first named there is much general
weakness and some emaciation, and in the third diarrhoea.

(c) In Egypt and other countries cases which used to be considered as idiopathic
anaemia are now known to be due to intestinal and other parasites, most of which may
be recognised by the presence in the faeces of ova or segments. Bilharzia hcBmatobia,
endemic in Egypt and elsewhere, causes anaemia and haematuria (§ 300). The fUaria
sanguinis hominis and strongylus gigas also give rise to anaemia.

The Ankyloitoma worm may be present in the intestine without symptoms, but
usually gives rise to anaemia and debility ; exceptionally the case may end fatally.
The less serious and earlier symptoms are bronchial catarrh, slight dyspepsia and
affections of the skin (papules, pustules and urticaria) due to the passage of the larvae
through it in the process of infection. Melaena is a common symptom. Occasionally
there are weakness of body and mind, amblyopia, apathy and melancholia. The two
ankylostoma worms, A. duodenale and A. americanum,exist in the adult state in the
intestinal tract of man. Their ova are voided with the faeces and undergo further
development in them if they are deposited on moist ground. The encapsuled larvae
gain access to the alimentary tract of man again by passing through the skin, then
the lungs, up the trachea and down the oesophagus. In their passage they give rise
to the symptoms mentioned in skin, lungs, and stomach.

The ditignosis rests on the finding of the characteristic ova in the faeces. The
possibility of a helminth infection must be borne in mind in obscure cases of anaemia ;
and the two factors which may suggest this are the occurrence of anaemia in epidemic
form, especially among miners, and the discovery of eosinophilia on examining the
blood.

The prognosis is good if the patient can be protected from further infection by
removal from any district where infection is rife, and especially from work in mines
in which the ankylostoma is known to exist. The only adequate method of pre-
vention is by burning the faeces and preventing their deposition in moist places, which
favour the development of the embryos.

684 GENERAL DEBILITY. PALLOR. EMACIATION [§411

TreaHmeiU. — ^The best anthelmintio is thymol. I>08e8 of \ drachm should be
given every hour or two hours for throe doses, and they will have to be repeated until
there are no ova discoverable in the faeces. It is important that the patient while
under treatment should not take. any alcohol nor fatty nor oily substances ; these may
dissolve the thymol and cause poisonous symptoms of absorption. Some patients
rapidly improve in health after segregation, without any drug treatment ; this must
be ascribed to the absence of reinfection. " Worm-carriers " — ^those whose fseoes
contain ova, but who have no symptoms of ankylostomiasis — should be treated* as
they are capable of canying infection.

Tricocephalni Dispar may cause anaemia and enteritis, sometimes a degree of fever,
depression and lethargy. The only diagnostic sign is the discovery of the ova in the
faeces (§ 215). The eggs mature in moist soil contaminated by the faeces of infected
persons. Treatment is the same as that for ankylostomiasis.

Taenia toUnm and T. mediocanellala rarely cause anaemia.

Bothriocephalni Latns is a tapeworm infecting those who eat fish containing tiie
cysticeroi. It occurs chiefly in Finland and Central Europe. The patient infected
by the bothriocephalus becomes anaemic, sometimes dangerously so. The tieatment
is similar to that used for taenia solium (§ 215) and anaemia.

Diitomiasii. — The earliest symptom is debility, usually combined with some degree
of anaemia which increases as the disease progresses, and is one of the chief factors in
producing a fatal termination. There is at the same time a diyness of the skin (well
known to veterinary surgeons) and general sjrmptoms of intoxication — eg,, fever,
malaise, loss of flesh, and slight jaundice. Owing partly to great anaemia and partly
to the involvement of the liver ascites appears. CEdema of the legs and of other parts
of the body follows, jaundice deepens, and death occurs by cardiac failure. When
the parasite is present in other parts of the body as well as in the liver, the symptoms
are more variable, and include abscess of the scalp or of the foot, cavitation of the
lungs, etc. Certain symptoms may arise owing to the rupture of the bile ducts in
which the parasite is lodged — e.g., genera] peritonitis or recurring attacks of pori-
hopatitis.

Etiology. — ^The sheep is the usual host of the adult fluke found in this country, the
Distoma hepaticum. In the East, infection follows the ingestion of the embryos of an
allied parasite, the Distoma sinense. The ova are passed out of the bile ducts of
infected animals and so occur in the faeces. If these are deposited near any fresh
water, the ovum grows into an embryo, which after certain stages passed in the body
of a snail, are conveyed back to man, cattle, etc., in drinking-water or encysted
on the leaves of vegetables or grass. From the gastro-intestinal tract they find
their way to the bile ducts and may p€kss through t^e liver and reach the situations
mentioned above. Wlie rover they settle they give rise to inflammation of the
neighbouring tissues. In the liver the resulting fibrosis leads to a spurious cirrhosis
of that organ, with consequent ascites, and jaundice.

Prognosis, — In many cases there are no symptoms at all ; in others, presumably
when the infection is severe or repeated, the train of symptoms above noted appears.
There is then little hope of cure as the parasites are placed in a peculiarly inaccessible
position. Symptoms of perihepatitis or of the presence of the parasites in the lungs
render the prognosis unfavourable.

The diagnosis rests on the discovery of the ova in the faeces or of the parasite (which
is about an inch long and half an inch broad) in any part of the body. The presence
of parasites may be first suggested by the examination of the blood, which reveals
eosinophilia, very marked in some cases.

TretUment is mainly symptomatic, but attempts may be made to wash out the bile
ducts with such drugs as euonymin, iridin, or hydrastin, starting with doses of 2 to
3 grains, and increasing if necessary. Other drugs with a cholagogue action prove
usefuL All possible measures must be taken to improve the general health.

Distoma Pulmonale (Sjmonym : Distoma Ringeri) is a parasite found in the lungs,
liver, testes, peritoneum, and brain. It is met with in Formosa (being present,
according to Manson. in 15 per cent, of the inhabitants). China, and other tropical
countries, where it gives rise to endemic haemoptysis. It measures 8 to 10 mm. in
length by 4 to 6 mm. in breadth. It is roddish-broMm in colour, oval in form. In the

§412 J AN JEM I A IN CHILDREN 586

long, its fovoorite habitat, it gives rise to ohronio oough without physical signs, msty
spatam, and irregular attaoks of hsBmoptysis, aooompanied by intense anemia. The
parasites are coughed up.

§ 412. AnsBmia in Children. — All the forms of an;(>nua above described
may occur in children under fourteen, and are produced by the same
causes which affect adults, but they occur in a very different order of
frequency and present certain marked differences, (a) The spleen tends
to become enlarged in all forms of ansemia in children, but is markedly
so in (1) splenic ansemia infantum, (2) lymphatic and myelogenous leu-
ksemia, and (3) Hodgkin's disease, (b) The blood changes also differ
considerably from the blood changes met with in the same diseases in
adults. In infancy and childhood slight causes lead to blood alterations
of a marked type which, if occurring in an adult, would signify severe
disease.^ (o) In secondary anaemias in children, as in adults, a diminution
of the haemoglobin is the earliest change, but there are important diffei*
ences. In childhood (1) the number of red corpuscles is reduced at a com-
paratively early stage and new ones enter the blood in a half-formed con-
dition— ^poikilocytosis and nucleated red cells — and (2) leucocytosis
occurs more readily, chiefly of the mononuclear cells (smaU and large
lymphocytes) owing to the activity of the adenoid tissue in children.
Adenoid tissue is very active and plentiful in children, and hence in
childhood an increase of the lymphocytes (which come from the adenoid
tissue and lymphatic glands) is more common than an increase of the
polynuclear neutrophil and other white cells (which come from the bone-
marrow). Thus in children among the leucocytic diseases Hodgkin's
disease, lymphatic leukaemia, and lymphosarcoma are more common
than spleno- myelogenous leukaemia.

I. Primary Anemias. — Pernicious ancemia is hard to diagnose with
certainty in a child, but it may occur. Chlorosis in childhood is so rare that
some authorities deny its existence. But blood changes with poikilo-
cytosis and nucleated red cells met with in the pernicious anaemia of adults
occur in the secondary anaemias of children more readily than in adults.

II. The chief causes of Secondary Anemia in children are defective
nutrition, the acute specific fevers, acute rheumatism, prolonged suppuration,
syphilis, tuberculosis, and chronic diarrhoea. Intestinal worms, and other
parasites, such as Bilharzia, may be for long an unsuspected cause of
anaemia and debility (§§ 2 and 215). Secondary anaemia frequently
occurs in children who have had deficient proteid food. It is met with
therefore in children who have been suckled too long, or have had only
milk food at an age when they should have had proteid foods containing
iron.

In addition to the foregoing, there are three anemias spboial to
CHILDREN — ^III. Infantile Scurvy ; IV. Splenic Anaemia Infantum ;
V. Congenital Anaemia.

1 See Dr. Robert Hutchison, " Disorders of the Blood in Early Life," the Lancet,
May 7, 1904.

686 GENERAL DEBILITY, PALLOR, EMACIATION [ § 41S

§ 418. in. Infantile Scorvy (Sjmonjrm : Barlow's Disease) used to be
considered a variety of rickets, but it is now known that it need not
necessarily be associated with rickets.

Symptoms. — (1) The onset may be gradual. The child is noticed to
become pale and in late stages profoundly ansemic. Muscular weakness
becomes marked, but emaciation may be absent. The child cries when
washed or dressed, screams if the legs are touched, and is very still when at
rest. (2) Very soon an ill-defined swelling which visibly increases is seen
along the tibia, just above the ankle. The swelling is not necessarily
symmetrical, and is due to subperiosteal extravasation of blood. The
legs appear as if paralysed, because the child keeps them everted and
motionless, dreading the pain caused by movement. Sometimes the
femurs are also affected, and there may be oedema of the dorsum of the
foot. The arms and scapulas are next affected ; the ribs, skull, and face
rarely so. The joints are free. (3) Swellings may occur in the muscles,
resembling abscesses, but there is no redness or fluctuation. (4) Sponginess
of the gums develops, and petechiss and internal hssmorrhages may occur
as in adult scurvy. (5) Other symptoms are albiuninuria and hsdmaturia,
and proptosis from hcemorrhage into the orbital periosteum. The tern-
ferature is normal except after large or recent haemorrhages, when it may
rise to 100° or 102° for a few days.

Diagnosis. — Infantile scurvy may be mistaken for rheumaUsmy but
whereas in rheumatism the joints are affected, in scurvy they are free.
Infantile paralysis is accompanied by no swelling or tenderness of the
limbs. With abscesses, nephritis, and stomatitis there are no signs of
scurvy. In syphilitic pseudo-paralysis crepitation and pain on moving
the limb occurs, due to separation of the cartilage from the diaphysis.

Prognosis. — On the whole this is favourable. Under treatment recovery
is rapid, and the child may be well in three weeks. If the patient is seen
at a late stage, or if from failure to diagnose the disease the diet is not
altered, death occurs from syncope or complications such as diarrhoea,
bronchitis, and pneumonia, or any of the acute specific fevers.

Etiology. — The disease affects children of six to eighteen months usually,
and is due entirely to defective diet — i.e., absence of fresh food. It occurs
particularly in infants fed only with proprietary foods, boiled, sterilised,
or condensed milk.

Treatment. — The prophylactic treatment consists in the observance of a
few simple dietetic rules. Fresh unboiled milk must be used, or the milk
must only be scalded (brought to the boiling-point for a second). Pep-
tonised milk and artificial foods should never be used for longer than a few
weeks at a time. Remedial treatment consists in the administration of
fresh milk. Steamed potato, rubbed through a sieve, and beaten up with
milk to the consistence of thick cream, should be given in doses of 1 drachm
to 1 ounce with each bottle. A few ounces of beef -tea, in which carrots
have been boiled, and then strained out, may be taken twice daily. Raw-
meat juice is excellent. For children of a year old, grape, orange, lemon,

414] SPLENIC ANEMIA IN CHILDREN 587

and baked apple juice, with potato pulp and raw-meat juice should be
given. Local treatment consists in wrapping the limb in cotton wool and
preventing movement.

f 414. IV. Splenic Anaomia ol Children (Synon3rm8 : Ansemia Infantum Pseudo-
leuksemia, von Jaksch's Disease, Anaemia Splenica Infettiva dei Bambini) occurs in
children from six months to two years of age, and is characterised by ansamia and
leucocytosis and enlargement of the spleen. The splenic ansemia of adults is not the
same disease.

Symptoms, — (i.) Pallor due to ansemia of insidious onset, sometimes preoeded,
sometimes followed, by (ii.) enlargement of the spleen, which may attain a great size.
Attacks of pain may occur, due to perisplenitis, (iii. ) The liver is moderately enlarged,
and in some cases the glands also. (iv. ) There is irregular pyrexia and gastro-intestinal
disturbance, (v.) The patient may remain plump throughout, but in severe cases,
usually becomes greatly emaciated, (vi.) In serious cases haemorrhages occur from
the mucous membranes and into the skin, (vii.) The blood changes are characteristic
— ^the haemoglobin is diminished, the number of the red corpuscles is reduced usually
to two or three million, and a slight degree of poikilocytosis is present, together with
nucleated red corpuscles. Leucocytosis may be absent in the earlier stages, but
always marked in the later stages. The polymorphous character of the leucocytosis
is a diagnostic feature. Myelocytes, lymphocytes, large mononuclear cells, and many
transitional forms are seen, the transitional forms rendering a differential count
impossible.

The Diagnosis is difficult only in the early stages. In both syphilis and rickets we
often meet with anaemia, enlargement of the spleen and of the liver ; but the spleen
never attains the same size, and the blood changes are never so marked, as in splenic
anaemia of infants. In children severe secondary anosmia may present leucocytosis,
but the polymorphism of the leucocytes is not foimd. Splenic leukcsmia rarely occurs
in children, and the leucocytosis has different features. The diagnosis of splenic
anaemia of children depends on different features at different stages ; and it would
appear, from the numerous synonyms above mentioned, that this disease has been
described by various observers, imder different names, according to the stage under
observation. In the early stage the changes in the red corpuscles are prominent,
resembling those in severe anaemia. In the later stages the leucocytosis becomes
more noticeable ; hence the name '' pseudo-leukaemia."

The Prognosis is good. The course is short, and recovery usually complete, but
oases relapse under bad hygienic conditions. Haemorrhages and petechial eruptions
are serious sjrmptoms. The lower the number of red, and the higher the number of
white corpuscles the graver is the prognosis. Death occurs £rom exhaustion or
intercurrent diseases.

The Etiology is obscure ; the disease is supposed to be due to some gastro-intestinal
toxin. It is often associated with rickets, and sometimes with syphilis.

The Treatment consists in remedying the causal conditions. Intestinal disorder
must be rectified. Fresh air is essential, and good food, such sis yolk of egg, raw-meat
juice, potatoes, and bone-marrow should be given. Of drugs, iron and arsenic are
the beet ; cod-liver oil and malt are useful adjuncts.

y. Congenital Anaemia occurs occasionally. The causes are obscure. No iron is
obtained during the period of suckling, but a child is bom with a store of iron in the
liver (Bunge), and it may be assumed that this store of iron has for some reason been
deficient. Sometimes there is a history of icterus after birth, as if there had been an
abnormal amount of blood destruction at that time. In other cases the bone-marrow
has been found to be defective. The condition is very apt to be confused with
oongenital syphilis.

OBOUP IL EMACIATION,

WASTiNa is a common sequence of nearly all acute and many chronic
diseases, but when it is the leading or only symptom the following morbid con-
ditions should be boine in mind. The fallacies have been referred to in § 393.

588 GENERAL DEBILITY, PALLOR, EMACIATION [§415

I. Malignant disease.

II. Defective feeding and digestive disorders, colitis, intestinal adhesions or stenosis,
and other obscure intestinal conditions.

III. Tuberculosis, diabetes mellitus. diabetes insipidus, chronic Bright*s disease,
syphilis, and other diseases of Groups I. and III.

IV. Diseases of the pancreas and other rare conditions.

V. Various nerve conditions.

Marasmus in children may be caused by defective feeding, diarrhosa, oonstipataon.
persistent vomiting, hereditary syphilis, rickets, tabes mesenterica, and pulmonary
tuberculosis.

Emaciation in the last third of life is suspicious of carcinoma ; in the middle third of
life, diseases in II. and III. above ; and in the first third, tuberculosis.

§ 415. I. Malignant Disease (Carcinoma and Sarcoma) is a cause of
emaciation which should be ever present in the mind when the patient
is at or past middle age. There are two anatomical varieties — carcinoma
and sarcoma. The essential feature common to them both is that they
tend to recur after removal, to invade the parts around, and to reproduce
themselves in distant parts. This is the clinical meaning of the word
malignant. Certain localities are much more prone to primary deposits
than others, and in cases of latent malignant disease it is important to
remember the places in which primary carcinoma and sarcoma may occur.
The commonest seats for primary carcinoma are the skin around the
mucous orifices, the tongue, oesophagus, stomach, colon, rectimi, mamma,
uterus, penis, and testis. In these regions secondary carcinoma is almost
unknown, unless by direct infiltrating invasion. Sarcomata are rarely
found primarily in these situations, but are prone to start in the glands,
the fascia, the bones, the corium, ovary, kidney in children, brain, spinal
cord, retina, and in the fibrous structures of the muscles, breast, and
testicle. Different varieties vary considerably in their malignancy and
rate of growth. The most rapidly growing of aU is the large round -celled
and the melanotic sarcoma, the slowest the Hbro-sarcoma. The myeloid
sarcoma is of slow growth, and rarely produces secondary tumours.
Melanotic sarcoma has a great tendency to reproduction in distant parts.
Among the carcinomata the softer and encephaloid varieties are more
rapid and malignant than the harder and scirrhous varieties. Any tissue
or organ of the body may be involved either by continuity, or along the
lymphatics (in the ease of carcinoma) or by the blood-stream (in sarcoma).

Symptoms. — The symptoms of malignant disease necessarily vary with
the situation, and under the heading of tumours or growths the diagnosis
has been previously dealt with {e.g., the abdomen, § 188, the chest, §§ 54
and 99). We are here concerned with a general review of the symptoms.
(1) There is loss of weight quite early in the disease, sometimes long before
any local signs can be detected. This is accompanied by a tjrpical
cachexia — i.e., an appearance of illness, in which the skin assumes an ashy
or sallow hue. The sallowness of the skin may be so marked as to be with
difficulty distinguishable from jaimdice, or even Addison's disease. (2) The
age of the patient is generally advanced in carcinoma, yoimg in sarcoma.
The four classical signs of cancer are pain, swelling, offensive discharge,

§ 416 ] MALIGNANT DISEASE 589

and hsamorrhage. (3) Pain at the seat of growth is often complained of,
especially in rapidly-growing varieties, or when they occur in tense parts.
(4) In accessible situations a thickening, swelling, or tumour may be
detected, which is usually hard, nodular, and apt to iix and infiltrate the
surrounding parts. Some sarcomata are soft and pulsating. (5) Whenever
the growth involves a mucous or epidermal surface there is an o£Eensive
pink or sero-sanguineous discharge — e.^., from the vagina. (6) In like
manner haemorrhage may occur, and take the form either of metrorrhagia,
cofFee-ground vomiting, or melaena ; and when the disease involves the
pleura or peritoneum the effused fluid wiU he blood-stained, (7) In carci-
noma the neighbouring lymphatic glands become enlarged and palpable.
(8) The rate of growth is rapid, though it varies widely in different forms
and localities. Scirrhous infiltration of orifices may only reach the thick-
ness of half an inch in six to twelve months, and the patient may live two
years ; but a round-celled sarcoma will reach the size of a hen's egg in a
month or two and kill in six.

Diagnosis, — Malignant disease may have to be diagnosed from aU the
other conditions which give rise to emaciation. A malignant nodule may
have to be diagnosed from syphilitic gumma (compare, for instance,
syphilis of the tongue, skin, etc.), but the latter is usually attended by less
pain and constitutional disturbance, and is amenable to auti-syphilitic
treatment. Cases of sarcoma are in rare instances attended by pyrexia.

The Prognosis, if the case is untreated, is always of the gravest kind,
the course rarely lasting more than one, or, at the outside, two years. A
few cases of undoubted malignant disease have undergone spontaneous
involution.^ The prognosis largely depends upon the stage at which the
true nature of the case is detected. On this depends very largely both
the prospect of arrest or removal. In general terms the prognosis also
depends on (1) the position and accessibility of the growth, how far vital
structures are involved, and whether it is on or near the surface ; (2) the
structure of the tumour {vide supra) ; and (3) the age of the patient, to
some extent, for growth is more rapid in the young.

Etiology. — (1) In carcinoma the age of the patient is nearly always o\er
forty, though I have seen cases of scirrhus of the pylorus in persons aged
twenty-eight and thirty- three. Sarcoma, on the other hand, may affect
children or adults of any age. Sarcoma is the commonest malignant growth
of the kidney that is met with under the age of nine more often than at
any other time of life. (2) Sex has not much influence, but the great
frequency with which cancer arises in the mammse and uterus gives to
statistics a marked bias towards the female sex. (3) Heredity has always
been regarded by most physicians as -a predisposing cause of malignant
disease, though it has been disputed by others. It is probable that
malignant disease is hereditary in the same sense as tuberculosis, by offering
a predisposition. (4) The question is still imder discussion whether cancer

1 See din. Soo. Trans., 1898-1899 ; Brit, Med. Joum,, July 20, 1907, and March 6,
1909.

688 GENERAL DEBILITY, PALLOR, EMACIATION [§416

I. Malignant disease.

II. Defective feeding and digestive disorders, colitis, intestinal adhesions or stenosis,
and other obscure intestinal conditions.

III. Tuberculosis, diabetes mellitus. diabetes insipidus, chronic Bright's disease,
syphilis, and other diseases of Groups I. and III.

IV. Diseases of the pancreas and other rare conditions.

V. Various nerve conditions.

Maraamua in children may be caused by defective feeding, diarrhoea, constipation,
persistent vomiting, hereditary syphilis, rickets, tabes mesenterica, and pulmonary
tuberculosis.

Emaciation in the last third of life is suspicious of carcinoma ; in the middle third of
life, diseases in II. and III. above ; and in the first third, tuberculosis.

§ 415* I. Malignant Disease (Carcinoma and Sarcoma) is a cause of
emaciation which should be ever present in the mind when the patient
is at or past middle age. There are two anatomical varieties— carcinoma
and sarcoma. The essential feature common to them both is that they
tend to recur after removal, to invade the parts around, and to reproduce
themselves in distant parts. This is the clinical meaning of the word
malignant. Certain localities are much more prone to primary deposits
than others, and in cases of latent malignant disease it is important to
remember the places in which primary carcinoma and sarcoma may occur.
The commonest seats for primary carcinoma are the skin around the
mucous orifices, the tongue, oesophagus, stomach, colon, rectum, mamma,
uterus, penis, and testis. In these regions secondary carcinoma is almost
unknown, unless by direct infiltrating invasion. Sarcomata are rarely
found primarily in these situations, but are prone to start in the glands,
the fascia, the bones, the corium, ovary, kidney in children, brain, spinal
cord, retina, and in the fibrous structures of the muscles, breast, and
testicle. Different varieties vary considerably in their malignancy and
rate of growth. The most rapidly growing of all is the large round-celled
and the melanotic sarcoma, the slowest the fibro-sarcoma. The myeloid
sarcoma is of slow growth, and rarely produces secondary tumours.
Melanotic sarcoma has a great tendency to reproduction in distant parts.
Among the carcinomata the softer and encephaloid varieties are more
rapid and malignant than the harder and scirrhous varieties. Any tissue
or organ of the body may be involved either by continuity, or along the
lymphatics (in the case of carcinoma) or by the blood -stream (in sarcoma).

Symptoms. — The symptoms of malignant disease necessarily vary with
the situation, and under the heading of tmnours or growths the diagnosis
has been previously dealt with {e.g., the abdomen, § 188, the chest, §§ 54
and 99). We are here concerned with a general review of the symptoms.
(1) There is loss of weight quite early in the disease, sometimes long before
any local signs can be detected. This is accompanied by a tjrpical
cachexia — i.e., an appearance of illness, in which the skin assumes an ashy
or sallow hue. The sallowness of the skin may be so marked as to be with
difficulty distinguishable from jaundice, or even Addison's disease. (2) The
age of the patient is generally advanced in carcinoma, young in sarcoma.
The four classical signs of cancer are pain, swelling, offensive discharge.

§ 415 ] MALIGNANT DISEASE 689

and heemorrhage. (3) Pain at the seat of growth is often complained of,
especially in rapidly-growing varieties, or when they occur in tense parts.
(4) In accessible situations a thickening, swelling, or tumour may be
detected, which is usually hard, nodular, and apt to fix and infiltrate the
surrounding parts. Some sarcomata are soft and pulsating. (5) Whenever
the growth involves a mucous or epidermal surface there is an offensive
pink or sero-sanguineous discharge — e.^., from the vagina. (6) In like
manner haemorrhage may occur, and take the form either of metrorrhagia,
coffee-ground vomiting, or melaena ; and when the disease involves the
pleura or peritoneum the effused fluid wiU he Uood-stained, (7) In carci-
noma the neighbouring lymphatic glands become enlarged and palpable.
(8) The rate of growth is rapid, though it varies widely in different forms
and localities. Scirrhous infiltration of orifices may only reach the thick-
ness of half an inch in six to twelve months, and the patient may live two
years ; but a round-celled sarcoma will reach the size of a hen's egg in a
month or two and kill in six.

Diagnosis. — Malignant disease may have to be diagnosed tvom all the
other conditions which give rise to emaciation. A malignant nodule may
have to be diagnosed from syphilitic gumma (compare, for instance,
syphilis of the tongue, skin, etc.), but the latter is usually attended by less
pain and constitutional disturbance, and is amenable to anti-syphilitic
treatment. Cases of sarcoma are in rare instances attended by pyrexia.

The Prognosis, if the case is imtreated, is always of the gravest kind)
the course rarely lasting more than one, or, at the outside, two years. A
few cases of undoubted malignant disease have imdergone spontaneous
involution.^ The prognosis largely depends upon the stage at which the
true nature of the case is detected. On this depends very largely both
the prospect of arrest or removal. In general terms the prognosis also
depends on (1) the position and accessibility of the growth, how far vital
structures are involved, and whether it is on or near the surface ; (2) the
structure of the tumour {vide supra) ; and (3) the age of the patient, to
some extent, for growth is more rapid in the young.

Etiology, — (1) In carcinoma the age of the patient is nearly always over
forty, though I have seen cases of scirrhus of the pylorus in persons aged
twenty-eight and thirty- three. Sarcoma, on the other hand, may affect
children or adults of any age. Sarcoma is the commonest malignant growth
of the kidney that is met with imder the age of nine more often than at
any other time of life. (2) Sex has not much influence, but the great
frequency with which cancer arises in the mammae and uterus gives to
statistics a marked bias towards the female sex. (3) Heredity has always
been regarded by most physicians as*a predisposing cause of malignant
disease, though it has been disputed by others. It is probable that
malignant disease is hereditary in the same sense as tuberculosis, by offering
a predisposition. (4) The question is still under disciission whether cancer

1 See Oin. Soo. Trans., 1898-1899 ; Brii, Med. Joum., July 20, 1907, and March 6,
1909.

690 QENERAL DEBILITY, PALLOR, EMACIATION [§416

is due to infection from outside sources, to peculiarity of cell growth, or to
the invasion of a low form of animal parasite or protozoon.

The only reliable Treatment of cancer is (1) removal as early as possible ;
the earlier and more freely this is done the more hopeful the result.
(2) In certain cases of malignant disease of the mamma removal of the
ovaries has been attended by involution of the growth. (3) The treatment
of malignant growths (more especially of sarcomata) by the injection of
mixed toxins (the virus of erysipelas and bacillus prodigiosus) was intro-
duced by Coley.^ A number of cases of sarcoma that had been given up
as hopeless after repeated operations were reported by Mr. C. Mansell
MouUin^ as having completely recovered under this treatment. (4) X-ray
treatment has proved efficacious in mammary and superficial skin cancer,
but so far it has not produced any lasting influence on the progress of the
internal cancerous deposits. (5) Trypsin has been administered in 20 to
30 minim doses daily by the mouth, combined with or followed in some
cases by amylopsin. Cases of involution of growth or abatement of the
S3m[iptoms have been recorded, but the results must at present be accepted
with caution. Thyroid also has given good results in certain cases.
(6) Vaccination with b. neoformans, an organism discovered by Doyen,
has been employed, and in certain cases the symptoms have been ameli-
orated and the rapidity of the growth has been checked. Little, however,
can be expected from this line of treatment, for the b. neoformans is
discredited by most pathologists as being the causal factor. (7) Quite
recently cases of undoubted carcinoma have been cured by radium.
Cancer of the mucous membranes, bowel, bladder, vagina, etc., can be
treated more conveniently by radium than by X rays. (8) Experiments are
being made (1912) to discover some chemical substance which will have a
selective action sufficient to destroy the malignant cells without injuring
normal cells, after the manner in which salvarsan afiects the spirochseta
pallida without endangering the life of the host.

II. Defective Feeding and Digestive Disorders. — ^Although malignant
disease or tubercle should always be remembered in obscure cases of
emaciation in the old and young respectively, perhaps the commonest
causes of slight loss of flesh met with in practice are defective feeding and
digestive disorders. Digestive disorders may of course exist without any
wasting, and if the latter be marked and the patient advanced in life it is
always suggestive of cancer of the stomach, especially if there be loss of
appetite. Defective feeding without digestive troubles, and particularly
deficiency in the fats and carbohydrates, may without any digestive
disorder be attended by emaciation. Defective teeth are a potent source
both of digestive troubles and loss of flesh. Various intestinal con-
ditions are often attended by undue spareness of body. Among the latent
causes of this may be mentioned obscure intestinal stenosis and catarrhal
colitis, both of which may be overlooked for a considerable time. Severe

^ Quy^s Hospital Oazetle, January 6, 1912.
2 Clinical Journal, April 6. 1898, p. 436.

i 416 ] MARASMUS IN OHlLDBM 591

diarrhoea is often followed by rapid wastdng, espeoially in children. Incipient
cirrhosis of the liver may also be remembered as a cause of emaciation.

III. Tnbefonlods often first makes itself known to us by an apparently
causeless loss of weight. Diabetes melutus and diabetes insipidus,
CHRONio Bright's DISEASE, and other diseases mentioned in Groups I. (ante)
and III. {j>08t) may first seek medical aid by reason of wasting. This is
particularly so in diabetes, where the inconsistency of his ravenous appetite
and constant thirst with loss of weight may even impress the patient.
On the other hand, some cases of diabetes, especially those which occur
later in life, are associated with a well-nourished if not a full habit of body.
Syphilis, so frequently a cause of wasting in infancy, rarely causes much
emaciation in the adult, though children affected with the hereditary
disease grow up stunted, slight, and delicate. In latent tuberculosis the
trunk and limbs may be wasted although the face be plump and rosy.

IV. Among the rarer causes of loss of flesh which should be remembered in obscure
oases are obscure visceral disease, and especially disease of the pancreas. Emaciation
frequently accompanies kala-azar, beri-beri, and myelopathic albumosuria.

V. Diseases of the nerrovs lyitem may sometimes start with or present generalised
wasting, such as bulbar paralysis, and the idiopathic myopathies (mostly met with in
childhood), but they usually present their proper symptoms.-

§ 416. Marasmus in Children. — Infants and children emaciate with
almost any disorder and with surprising rapidity. A sudden attack of
diarrhoea may give rise to loss of flesh in twenty-four hours.

The principal causes are eight in number :

(a) Those which occur chiefly under two years of age : (1) Defective or
improper food or feeding ; (2) those associated with diarrhoea or constipa-
tion ; (3) those associated with persistent vomiting ; (4) hereditary syphilis ;
and (5) rickets.

(b) Those which are met with chiefly after two years of age : (6) Tabes
mesenterica ; (7) pulmonary tuberculosis.

(1) Defective Feeding constitutes the commonest cause of emaciation
amongst the children of the lower classes. Such children are always fretful,
the bowels are irregular and often constipated, the stools, instead of being
the normal orange colour of infancy, become either green, grey, or white
and " chippy " with particles of undigested food. The error may consist
of over-feeding, under-feeding, mal-assimilation or a defect in the quality of
the food or the time that it is administered. Over-feeding is perhaps more
common than the reverse. Undiluted cow's milk is very indigestible, and
mothers of all classes have a tendency to make their child's feeds too strong
and to give them too frequently imder the notion that it will make a child
" grow strong." The mother's milk, when she is out of health, or when
lactation has been too prolonged, may be of too poor a quality to afiord
adequate nutrition. Preserved milks and foods taken for too long a time
without any fresh milk lead to scurvy (§ 413). A suitable dietary, which
is within the reach of all classes, has been given in § 212a, ante, A good
way of giving cod-liver oil (which is a very nourishing food) to children is
to pour away the oil from a box of sardines and replace it by cod -liver oil.

692 GENERAL DEBILIT F, PALLOR, EMACIATION [ § 417

After standing for twenty-four hours the oil becomes flavoured with the
sardines, and both can be given together.

(2) DiARRHCEA or CONSTIPATION, either alone or alternating, are potent
causes of wasting in infancy and childhood, and these are frequently due
to dietetic errors or want of care and cleanliness in the nursery. The
subject of infantile diarrha^a is fully discussed in § 218. Many cases of
chronic diarrhoea in childhood will yield to mistura ricini calcis (F. 64).
Chronic constipation will undoubtedly result in marasmus. In a family
with which I was well acquainted the first two children died of marasmus
associated with the most obstinate constipation, probably due to a chronic
colitis ; the case of the third child, which the mother stated exactly
resembled the others in all particulars, was following the same fatal course
until systematic treatment by mbt. ricini calcis resulted ultimately in
restoration to health.

(3) Persistent Vomiting is another cause of wasting in childhood.
Like the preceding, it may be due to errors of diet, especially too frequent
or over-feeding, or to gastro-intestinal catarrh. Careful dieting, lime-
water, and proper intervals between the feeds will cure most cases. The
reflex and other causes of vomiting (§ 191) must be considered when simple
treatment is unavailing. In intractable cases feeding by the nose has
been resorted to. Hypertrophic stenosis of the pylorus is a rare local cause
of vomiting in infants.

(4) Hereditary Syphilis is a cause of wasting in some families. It
is generally accompanied by snuffles or skin lesions of some kind (§ 404).
The manifestations of hereditary syphilis always appear during the first
year of life, generally during the first six months.

(5) Rickets (§ 447) may be accompanied by wasting, but, as Dr. Judson

Bury aptly remarks, '' fat rickets are commoner than lean rickets." This

disorder is recognised by the characteristic bone changes, generalised

sweating, and generalised tenderness. Rickets may appear at any time

between the sixth to the eighteenth month of life ; very rarely after two

years of age.

, § 417. (6) TabeA Meienterioa is a wasting disorder occurring for the most part in
children of two years and upwards, due to tuberculosis of the mesenteric glands.

Symptoms. — ^The onset is very insidious, and fnay extend over many months.
Gradually the limbs and face become shrunken, and there are ansmia, listlessness.
vague attacks of pyrexia, and sometimes abdominal cramps. The leading physioal
sign is the enlarged abdomen, which is generally tympanitic on percussion. Some-
times the enlarged glands can be felt, but more frequently there are localised thickenings
and masses, which give a doughy feeling, due to chronic tuberculosis of the peritoneum.
Attacks of diarrhoea with offensive stools occur from time to time.

The Varieties depend upon the extent to which the tuberculosis affects the peri-
toneum as well as the mesenteric glands. If the peritoneum is extensively affected,
ascites or matting of intestines is t^so present (§ 176). There is no doubt that many
cases of primary tubercidous peritonitis are still called tabes mesenterica. Sometimes
the disease runs a more acute course with pyrexia, and resembles enteric fever, from
which it can only be differentiated with difficulty.

Diagnosis, — In addition to the diseases just mentioned tabes mesenterica may have
to be distinguished from the distension of the bowels due to improper feeding, in
which there is generally no pyrexia, no resistant masses, and disappearance on regu-

§ 417 ] QRO UP IIL^DEBILIT Y 593

lating the diet. RickeU may be attended by a distended abdomen, but has not usually
marked emaciation, and the characteristic rachitic changes in the skeleton differentiate
it. Morbus cceliacus, a condition occurring in children, in which wasting is accom-
panied by atonic dilatation of the intestine, and frothy, porridge-like, offensive
motions, may be difficult to distinguish, but no glandular masses can bo felt.

Prognosis. — ^The course of the malady is apt to be irregular, with intervals of
apparent recovery, followed by relapses. Sometimes the glands undergo a fibroid
change, and what appear to be the most unlikely cases recover. Among the untoward
symptoms are acuto local pain and tenderness, indicating peritonitis ; constant
(Uarrhcea, indicating ulceration of the bowels ; and the evidences of tubercle elsewhere.
The complications are numerous — ulceration of the bowels, attended by pyrexia and
intractable diarrhcea ; goneral tuberculosis ; abscosses forming and bursting in various
situations, such as into the peritoneal cavity or from the umbilicus, the latter forming
a chronic fistula. Intestinal obstruction may result at any time from the formation
of bands of adhesion.

Etiology. — ^Tuberculosis of the mesenteric glands (tabes mesenterica) may occur
at almost any age. I have met with it at twelve months and also at the age of forty-
five, but it is relatively rare under two years of age. Male children appear to be
more prone than females. The introduction of the tubercle bacillus is the proximate
cause, and it has been generally supposed that this is introduced by the ingestion of
milk from tuberculous cows, or milk which has otherwise become contaminated. If
the mucous membrane of the alimentary canal is healthy, there seems to be less risk
of contamination.

TreatmerU. — Prophylactic measures consist in sterilising or Pasteurising the milk,
and regulating the supply whence it is obtained. The disease has undoubtedly
become less frequent, and it seems probable that it will ultimately be stamped out.
In the remedial treatment the diet needs careful attention, both in its quantity and the
quality. All food should be raised to the boiling-point before administration. Small
doses of creosote by the mouth or by enema, together with tonics, cod-liver oil, iodide
of iron, and other remedies mentioned under Phthisis (§ 94), are employed. Among
local measures mercurial or iodoform ointment rubbed into the abdomen has proved
valuable in many cases.

OROUP HI. DEBILITY ONLY (ASTHENIA).

The causes of debility not necessarily accompanied either by pallor or
emaciation are as numerous as those of the two preceding groups, and it
must be remembered that all the disorders in both of those groups may
commence with weakness only ; in short, the majority of chronic disorders
begin with debility. The fallacies (§ 393) and methods of examination
have already been given.

Commoner Causes. I Rarer Causes.

I. Senile decay and arterial disease. I. Myxoedema.

II. Chronic interstitial nephritis.

III. Neurasthenia, or other incipient

or obscure diseases of the ner-
vous system.

IV. Chronic dyspepsia and obscure dis-

eases within the abdomen.
V. Cardiac, tuberculous, and other
obscure diseases within the chest.
VI. Diabetes mellitus and diabetes in-
sipidus.
VIL Conditions referred to in Groups I.
and II., in which ansamia or
emaciation are ill-marked.

II. Addison's disease.

III. Bronzed diabetes.

IV. Disease of the pancreas. Graves'
disease, myelopathic albumosuria,
acromegaly, beri-beri, pellagra,
and many other conditions men-
tioned in Groups I. and II.

o94 GENERAL DEBILITY, PALLOR, EMACIATION [§418

When a patient U suffering from debility or loss of vigour of mind and body,
without any very marked pallor or obvious loss of flesh, and without any marked
physical signs or other evidences of disease, in the first half of life one would suspect
neurasthenia, chronic dyspepsia or gastro-intestinal disorders, incipient or latent
tuberculosis, diabetes.

In the second half of life one would suspect senile decay, chronic interstitial nephritis,
obscure cardiac valvular or aortic disease, diabetes, myzoedema, Addison *s disease.

And failing these, some of the conditions previously mentioned among the anemic
or wasting disorders (Groups I. and II. )•

§ 418. I. Senile Decay and Arterial Disease. — ^As we advance in years
the power both of body and mind notably declines. This should not
be very obvious under sixty, but the age at which it appears differs con-
siderably in different persons, and still more in different families, for the
onset of decay in persons, as in plants and animals, is largely a question
of heredity plus the previous habits of the individual. Structurally
there is a universal tendency to atrophy or degeneration of the parenchyma
or functionally active tissues, and slight increase in the lower forms of
tissue (such as iibro\is and supporting tissues) in all the organs and struc-
tures of the body. This is particularly seen in the cardio-vascular system
where it is the muscular coat — i.e., the functionally active tissue of the
arteries which first shows signs of senile degeneration.^

Symptoms. — Consequent on the changes just mentioned there is a
universal lowering of vitality and nutrition, and the general enfeeble-
ment of thought, word, and act which results in the mumbling, fumbling
and stumbling of old age. Physical weakness comes on so slowly that
even the patient himself is hardly aware of it, and it is not sufficiently
recognised that widespread disease of the arteries alone may give rise to
progressive mental and bodily enfeeblement at whatever age it comes on.

The following case may be quoted by way of illustration : Jessie T was

admitted into the Paddington Infirmary in 1889 at the age of forty -nine. At the
age of forty-five she began to complain of muscular and mental weakness. This
gradually increased, so that at the time of admission she could only walk by push-
ing a chair before her, and the case was thought, therefore, to be some kind of para-
plegia. There were absolutely no physical sig^s in any organ and no evidences
of disease in the nervous system at any time, and the urine was always normal. She
became progressively more and more enfeebled in body and mind, g^radually took
to bed, and died, ten years after admission, of progressive asthenia. I was present
at the autopsy in 1899, and all the organs were normal, both macro- and micro-
scopically, with the exception of atrophy ; but there was extreme and widespread
disease of all the arteries of the body and of the brain, the main change being granular
degeneration of the muscular coat of the heart and arteries, with consequent jdelding
and great dilatation of the arteries. In infirmary work I have met with arterial
disease in persons as young as thirty-eight and forty — cases which were examined
post-mortem — and weakness was the only symptom.

The condition of the heart and aorta should be carefully noted, especi-
ally any rigidity of the latter, as shown by accentuation of the second
sound at the base and the character of a pulse- tracing (Fig. 31, § 66).
The arterial tension should be noted from day to day, and the walls of
the superficial arteries carefully investigated (§ 65 et seq.). Among the

1 " On Senile Decay," Trans. Med. Soc. of Lond., 1897 ; and " On Arterial Hyper-
myotrophy and Medial Sclerosis," Trans. Path. Soo. of Lond., 1904.

§418] SENILE DECAY 596

later s3nnptoms associated with senile decay of the cardio-vascular and
other tissues, perhaps vertigo is the commonest. A large number of other
vague cerebral sensations may be experienced, and even convulsions
(senile epilepsy) may occur. The urine should always be carefully and
repeatedly examined so that senile decay may not be confused with other
causes of debility (infra), particularly chronic interstitial nephritis.

The Prognosis depends a good deal upon the amenability of the cardio-
vascular system to treatment. The diseases to which old age is mos^
liable are of a chronic and degenerative nature, the arterial — i.e., the
nutritive system being responsible for this, and itself showing the most
definite and widespread signs of degeneration. The immediate cause of
death in old age is usually some pulmonary complication. An analysis
of 409 fatal cases in persons of sixty years of age and upwards, who died
consecutively in Paddington Infirmary — February 1, 1886, to December 31,
1892, showed that 121, or 30 per cent., died of some pulmonary condition
other than tubercle (pneumonia, bronchitis, hypostatic congestion, and
pulmonary apoplexy). The next most fatal disease was cancer, 62 cases
(15-5 per cent.), then simple senile decay, 35 cases (9 per cent.), then
contracted granular kidney, 24 cases (6 per cent.), then pulmonary tuber-
culosis, 22 cases (5-5 per cent.).

The Treatment should be mainly directed to the cardio-vascular system,
and especially to the raising of low blood-pressure (§ 62) and the lowering
of high blood-pressure (§ 61). Stimulants are nearly always called for
in the treatment of disease in the aged. The food should be light, nutritious,
and easily assimilable, and small in quantity ; it is wonderful how small
a quantity of food the aged require, and it has been reckoned that 12
ounces of solid food per diem are sufficient. It is not only useless but
harmful to over-feed the aged ; keep them warm and prevent chill, but
do not over-feed them. Strychnine is par excellence the tonic of the
aged.

II. Chronic Interstitial Nephritis (§ 297) (Chronic Bright's Disease),
should always be remembered as a cause of progressive enfeeblement
coming on at or past middle life. It is indeed very apt to be mistaken
for senility, and failing vigour is the leading symptom for which the
patient seeks advice in a large proportion of both these conditions. Some-
times this weakness is accompanied by generalised muscular wasting,
but quite as often there is none. The complexion is generally sallow, but
there is no definite pallor till late in the disease. Headache is common,
chronic interstitial nephritis being one of the commonest causes of head-
ache coming on after middle life.

m. Nenrasfhenia (§ 523) and various other functional and degenera-
tive conditions of the nervous ssrstem may be evidenced by general weak-
ness. This is particularly the case in the functional disorders, such as
neurasthenia and hysteria, where the weakness may amount to complete
prostration. Such cases are usually met with in the first half of life or
middle age. Among the gross lesions which are apt to come on insidiously

596 GENERAL DEBILITY, PALLOR, EMACIATION [§419

with weakness are paralysis agitans, bulbar paralysis, and frontal cerebral
tumour — diseases more often met with in the second half of life. Myas-
thenia gravis is a rare condition, coming on usually with generalised weak-
ness ( see also Generalised Paralyses, § 573).

IV. Chronio Dyspepsia, gastric dilatation, and other obscure diseases
within the abdomen may be attended by debility only for a long time.
Gastro-intestinal troubles produce it by chronic toxaemia and mal-assimila-
tion of food. Mucous colitis may be specially mentioned in this con-
nection, also appendicitis^ abdominal cancer, and many of the other con-
ditions mentioned in Chapter IX.

y. Obscmre Diseases within the Chest may be manifested by general
weakness. Itunpient tuberculosis of the lungs should always be remem-
bered in cases of unexplained general debility, especially in yoimger
subjects. In the second half of life, and especially in those with an alcoholic
history cardiac enfeeblement and fatty heart (§ 52) may cause no other
symptom than debility, and the same may be said of athearysm of the
third part of the aorta.

VI. Diabetes Mellitns and Diabetes Insipidus are often first revealed
by progressive weakness, though our attention may also be drawn to
these conditions by the thirst, polyuria, emaciation, or glycosuria (§§ 309
and 310). These diseases may occur in either the first or the second
half of life.

The rarer causes of debility not necessarily accompanied by pallor or
emaciation are Myxoedema, Addison's disease. Diseases of the Pancreas,
Acromegaly, and some of the conditions mentioned in Groups I. (ansemia),
and II. (emaciation).

§ 419. I. MyxoBdema (mi'^a, mucus ; oidrjfia, swelling) is an insidious disease evi-
denced by weakness, Ic thargy , and other manifestations of deficiency in the metabolic
processes of the body, duo to diminished thyroid function. It was so named by the
late Dr. W. M. Ord, on account of the mucoid degeneration which takes place in the
subcutaneous tissue throughout the body, and is the most obvious anatomical change,
producing a kind of solid oedema. It was at first believed by him to constitute a new
and hitherto undescribed form of generalised oedema, but it is now known — and this
was admitted by him — to be in reality a sporadic cretinism (§ 138) occurring in adult
life. It is due to a diminished function of the th3rroid gland, generally accompanied
by a diminution in volume of the organ. It is not a very uncommon disease, but is
frequently overlooked.

Symptoms, — The weakness here takes the form of a very characteristic slowness
of action, of thought, and of speech. It comes on very gradually, and the patient
frequently seeks advice for some other reason. (2) The aspect (Fig. 1, § 9), howev^*,
is so characteristic that when the doctor has once seen a case he recognises it again
directly. The face is slightly puflfy, and, the lines of expression being obliterated,
it appears immobile and vacant ; the puffiness of the eyelids may be mistaken for
dropsy ; the malar capillaries are injected, and cause a characteristic flush on each
cheek. The hair of the scalp and eyebrows is scanty, and brittle. The speech is slow
and drawling, the hands are flat, pufiy, and spade-like, and the nails brittle. All
the movements are slow, and the mental processes lethargic. (3) As the d»9f>»Bp
advances, the skin of the whole body is thickened, and at first sight gives the appear-
ance of generalised dropsy ; but myxoedema may be distinguished from the Utter
by the absence of pitting ; pufiy swellings may be notic^ above tiie ola video.
(4) There is great mtolerance of cold ; the skin is dry and scaly ; perspiration neTer

$480] MYXCEDEMA— ADDISON'S DISEASE 597

occurs. Psoriasis is common. (5) The pulse rate is slow and may drop to 40 boats
per minute.

Diagnosis. — The disorder may be mistaken in its earlier stages for aruBmia and
the other disorders mentioned in Group I., also for tho other causes of debUiiy
now being considered ; but the facial appearance is very charactoristic. It may be
diagnosed from chronic interstitial nephritis and other forms of chronic renal disease
by the absence of pitting on pressure and the absence of the urinary changes of ronal
disease.

Prognosis, — Before the introduction of the thyroid treatment patients rarely lived
more than a few years, dying usually of some intercurrent malady or complication.
Mental changes, such as hallucinations, and even dementia, may supervene. Menor-
rhagia and other hsemorrhages are sometimes associated with the disease.

Eiiology. — The disease is much more frequent in women, in whom it supervenes
usually about middle life. It is undoubtedly due to a deficiency of thyroidal function
(Athyroidism, § 138), but what constitutes the proximate cause of thyroidal atrojjhy
is not known. It is certainly not confined to any particular district as is endemic
cretinism, and it differs from the latter in the ago and sex which it chiefly affects.

Treatment. — The treatment by the internal administration of the thyroid gland
is so certain and efficacious that this may be used as a means of diagnosis. Tabloids
of the extract, i to J gr., very cautiously increased, may be administered twice or
thrice daily after meals. The usual dose of 5 grains is too largo ; much harm is done
by such doses. Tho drug must never be pushed to tho point of producing tachycardia.
Complete recovery may ensue after a few weeks' or few months' treatment. Relapses
are very apt to occur upon ceasing the thyroid administration and the patient may
be obliged to continue treatment indefinitely.

§ 420. II. Addiion'f Diseaie is a rare malady, described by Dr. Addison ^ in 1854,
characterised by progressive loss of strength and general pigmentation of the skin,
due to disease of the suprarenal capsules. The most common morbid change in tho
latter undoubtedly is tuberculosis, which may go on to caseation, fibroid, or other
changes. Occasionally the suprarenals are affected in this disorder by malignant
and other disease.

The Symptoms come under five categories : ( 1 ) Progressive general weakness is
its most marked feature and may appear long before any other symptom. It is
unaccompanied, as a rule, either by anaamia or marked emaciation until perhaps
towards the end. Uncomplicated cases present a sub-normal temperature through-
out. (2) PigmenieUion of the skin of a more or less general distribution ensues sooner
or later. The colour begins with a yellowish tint, which gradually deepens into a
bronze mahogany colour. The localities most affected are the exposed parts (the
face, neck, and hands), those where pigmentation is normally present, such as the
axills and nipples, and sites of pressure {e.g., waist). The edge of a patch of colour
shades gradually into the healthy skin around, which makes it difficult to discover
such a patch in its early stage. The mucous membranes of the tongue, mouth, and
throat frequently present the same kind of patches. (3) Gastric symptoms generally
occur at some time, such as vomiting, hiccough, and cramp-like pains in the abdomen
and loins. Pains in the limbs may also be complained of. The bowels are often
constipated, but sometimes there is intractable diarrhoea, which may be fatal.
(4) Cardio-vascvlar symptoms may be present — palpitation, dyspnoea, sighing, yawning,
and later on a tendency to collapse. The small rapid pulse, with very low blood-
pressure (70 to 90 millimetres of mercury), is almost of itself sufficient to warrant a
diagnosis. (5) Nervous symptoms are less common, but may consist of headache,
vertigo, and nervousness. The mind is clear, except towards the end, when delirium,
convulsions, or coma may sot in. These five groups of symptoms vary in their
predominance, but asthenia is always present, and pigmentation nearly always.
There are two varieties — acute and chronic.

The Diagnosis is often very difficult on account of the vagueness of the symptoms,
the absence of physical signs, and the resemblance of the pigmentation to various
other cachectic states, especially cancer. Cancer of the pylorus is accompanied by

^ ** On the Constitutional and Local Effects of Disease of the Suprarenal Capsules,"
London, 1855.

598 GENERAL DEBILITY, PALLOR, EMACIATION [§421

sallowness, which is often mistaken for the pigmentation of Addison's disease. Both,
moreover, are accompanied by enfeeblement, gastric pain, and vomiting. The
diagnosis from other pigmentary conditions is given among the causes of pigmentation
(§ 496). Slight jaundice, the pigmentation of malaria, chloasma, and arsenical pig-
mentation must be borne in mind. Chronic BrighVs disease, neurasthenia, and otiier
conditions attended by asthenia mentioned in this group are apt to bo mistaken
for the disease.

Prognosis. — ^The course of the disease is progressive, and usually prolonged ; it
may last one to ten years. There are frequent relapses, with intermissions of com-
parative health, but it always terminates in death. It may end suddenly with syncope,
severe vomiting, and diarrhoea, convulsions, or coma, or it may terminate gradually
by asthenia. The commonest complication is tuberculosis of the lungs, or elBewhere ;
and pulmonary tuberculosis is the commonest cause of death.

Etiology, — Patients are usually about middle life, and by far the larger number
are males. The essential cause is disease, often tuberculous, of the suprarenal
capsules.

Treatment. — Suprarenal extract may be tried in tabloids containing 1 grain (equiva-
lent to 15 of the gland) twice daily, and in gradually increasing doses. The pathology
of the disease rests upon the loss of the internal secretion of the suprarenal bodies,
and if the secretion can be made good the fatal issue should be averted ; suprarenal
extract and fresh gland, however, have not been successful in arresting the disease
hitherto. The symptomatic treatment consists in rest, and supporting the strength
by cod-liver oil, tonics, good nourishment, and hygienic living, on the same principles
as other tuberculous affections. Cold and over-exertion should be avoided.

§ 421. III. Bronied Diabetef, or what should more properly be called " pigmoitary
cirrhosis of the liver with glycosuria," is a rare condition which might be mistaken for
Addison's disease. In certain cases of hypertrophic cirrhosis of the liver there is a
considerable amount of hcemo-chromatosis, which may give rise not only to the symp-
toms characteristic of cirrhosis, but to deBnite pigmentation of the skin. Gutain
of these cases may also be associated with a more or less permanent glycosuria, possibly
owing to concurrent cirrhosis of the pancreas. The glycosuria usually occurs as a
late event in such cases.

^ IV. Digease of the Pancreas, acromegaly, Oravei' difease, myelopathic albomomria,
beri-beri, pellagra, and other conditions mentioned in Groups L and n. (q.v.), may come
on with debility only, or the patient may seek relief for debility.

CHAPTER XVII

THE EXTREMITIES

In the preceding pages we have seen on several occasions that so-called
local diseases, such as pneumonia and endocarditis, have by scientific
research been shown to be only local manifestations of a general microbic
infection. This pfinciple will here again be illustrated, for a gouty joint
is only the local evidence of disordered metabolism, and acute rheumatism
is probably microbic in origin. My own belief is that all joint diseases
(other than traumatic) are but local manifestations of some toxic, septic,
or infective blood condition. In conformity, however, with the scheme
of this work, whereby all diseases are approached from a symptomatic
standpoint, certain diseases, the symptoms and physical signs of which
are referable mainly or entirely to the upper or lower extremities, will
now be considered.

PABT A. SYMPTOMATOLOGY.

The CARDINAL SYMPTOM referable to the extremities is pain (or painfid
sensations of some kind), which may or may not be accompanied by
some phsrsical change.

§ 422. Pain in the Limbs should be investigated, like pain in other
situations, as to its 'position^ character ^ degree, constancy, and duration.
Its position may be localised to the skin, or to a joint or any other struc-
ture, or be generalised, as in sheer exhaustion ; its character may be sharp
and shooting (as in tabes) or dull and heavy (as in vascular lesions), or
like pins and needles (as in nerve and neuro- vascular lesions). The skin,
subcutaneous tissues, nerves, muscles, and vessels must be examined
for a local cause ; but it must be remembered that pains in the limbs,
especially in the legs, may be due to a generalised infection which may
not be evident for some time after the onset of the pain. So also disease
of the brain, spinal cord, chest, or abdomen may be the causal condition ;
hence a thorough examination including investigation of the urine, blood
and even lumbar pimcture, may be necessary in obscure cases. Pain in
the limbs may come on acutdy or insidiously.

(a) Acute fain in the limbs coming on more or less suddenly may
herald influenza, enteric fever, malignant endocarditis, variola, scarlatina,
or some other specific fever. In many cases of influenza this pain and
slight pyrexia are the only symptoms. Acute rheumatism also comes

599

600 THE EXTREMITIES [ §

on rapidly with pains referable to the muscles, bones or joints, and so does
dengue ("break-bone" fever). Trichinosis is attended by excruciating
muscular pain in the second stage of the disease, when the parasite begins
to migrate. A sudden sharp pain in one spot in the limb is felt when
emboHsm of an artery occurs ; so also in thrombosis of a vein. In both
cases pyrexia may be absent.

(6) Pains in the limbs coming on more or less insidiously may be due
to (1) peripheral neuritis, and therefore all its causes — c.^., alcohol, diph-
theria, or syphilis. Long before such a disease as neuritis was recognised
by the profession ** pains in the limbs " were known to arise from exces-
sive indulgence in alcohol, and in dealing with alcoholic subjects this
should be remembered. The same pains may occur in neurasthenia, and
it is quite possible that the pathological condition in this disease, as in
alcoholism, neuritis, and the acute specific fevers, may be a toxic condition
of the blood. (2) Pains in the joints or muscles are* characteristic of
chronic rheumatism, rheumatoid arthritis, osteoarthritis, and gout ; when the
pain seems to be in the bones syphilis should be suspected. (3) Pain
affecting the nerves has a shooting or darting characteristic of its own,
as in neuralgia and sciatica or tabes dorsalis. (4) Growing pains
(so-called) in children are often of a somewhat serious import, as
being the only tangible evidence in them of subacute rheumatism, which
may nevertheless be sufficient to produce endocarditis with permanent
damage imless the condition is recognised and rest in bed with salicylates
prescribed. (5) Varicose veins are a frequent cause of pain in the legs
and feet. (6) The " numbness " or tingling of the hands and feet known
as acroparaesthesia (a word which indicates perverted sensations in the
extremities) is very characteristic ; it may be indicative of some vaso-
motor disorder such as erythromelalgia (§ 429), or the incipient stage of
tabes, general paralysis, or other organic disease. (7) Severe pain in the
foot should lead us to suspect flat foot or metatarsalgia. Metatarsalgia
is a neuralgia of the foot due to lateral displacement of the heads of the
metatarsal bones which press upon the nerves, and may also produce a
com (for which, indeed, the patient may seek advice).^ (8) Various
diseases of the bones (§ 446) may come on insidiously, with nothing more
definite than vague pain in the limb or limbs. This must be specially
remembered in children in whom pains of gouty or alcoholic origin are
rare. Various forms of inflammation, acute or chronic, may arise, and
unless the bone be superficial there may be no surface indications at all.
Some of them, such as osteomyelitis, are very serious, and require prompt
recognition. Disease of the vertebrae and pelvis are causes of pain in the
limbs frequently overlooked. (9) A muscular strain or rupture of some
muscular fibres may leave a chronic pain and partial loss of function
(unattended by any physical sign) which is often hard to cure. In one
of my cases the pain letted over five years. (10) Local injury or pressure
may cause pain, such as injury from a crutch, or sleeping in a cramped

^ J. Jackson Clarke, the Medical Press and Circular, June 14, 1899.

§42S ] INSPECTION OF THE LIMB 601

position, or Ijrmphatic glands or other tiunours in the axilla, neck, or
pelvis. Shooting pains down the arms, especially the left, occur in
aneurysm of the aorta and angina (see also Causes of Single Nerve Paralysis,
§ 569). A careful examination of the chest should be made, for pain
down the arms may indicate disease in that region ; e,g,, cardiac disease,
aneurysm or other mediastinal tumour.

PABT B. PHYSICAL EXAMINATION,

The physical signs referable to the extremities mainly consist of some
visible or tangible alteration in the skin and general contour of the limb,
the joint, the muscles, the bones, or the vessels and nerves.

§ 428. Inspection of the Limb may reveal generalised redness or alteration of
colour, (Bdema, variooso veins, or somo other diffuse or localised swelling. Eruptions
prone to affect the skin of the extremities are specially dealt with in Chapter XVIII.

Even without the skill of a palmist or the acumen of a Sherlock Holmes a great
deal concerning the temperament, habits, and diseases of a patient may be learned
by a careful inipection of the handi. For instance, the long, thin, dextrous fingersi
perpetually on the move, will almost surely indicate a nervous temperament and
imaginative disposition, just as the short, thick, almost clumsy fingers and hands
of another will bespeak slowness, deliberation, and doggedness. The occupation of
a patient may often be learned from a glance at the palms. Some people habitually
have cold, damp, clammy bands, and these are generally the subjects either of the
alcoholic habits or the rheumatic diathesis, occasionally somo other condition causing
a defective vaso-motor tone. The nails can also afford us some information. They
are dusky in all conditions of impaired circulation, and pale in aneemia ; compression
on the tip of the nail should not completely empty the capillaries, as it does in ansemia.
In aortic regurgitation compression of the nail tip reveals a capillary pulsation. A
transverse ridge or groove in the nails indicates an arrest of growth, and may mark
the date of an illness or any disturbance of nutrition, of even so slight a nature as
seasickness.^ It is useful to remember that the nail takes about five or six months
to grow from root to tip. Various distortions of the nail occur in neuritis and injury.
Pitted, dark, and discoloured nails may be due to eczema, psoriasis, or ringworm.
In the latter case scrapings of nail softened in liq. potasssB reveal the fungus. Gubbed
fingers — i.e., fingers with a bidbous end and great convexity of the nails (filbert-
shaped nails), are characteristic of congenital cardiac disease or valvular disease in
early life. Pulmonary osteo -arthropathy, emphysema, chronic phthisb and any
disease attended with profuse expectoration may be attended by the same deformity.
Olossp fingers (fingers with smooth, thin skin) are the result of a neurotic dystrophy,
and are associated with destructive and paralytic lesions of the nerve trunks ; they
also occur in sclerodermia. Dactylitis is a thickening of one phalanx due to disease
of the bone, with infiltration of the tissues of the fingers, resulting in a deformity
known as the " champagne bottle finger." It is met with chiefly in tuberculous,
and sometimes syphilitic, children. '' Heberden's nodes," lipping and distortion of
the phalangeal joints, are in reality osteo-arthritis of the fingers. Gouty nodules of
urate of soda form white masses near the joints, just beneath the skin, and have an
external resemblance to Heberden's nodes. The bone ends of the wrists are enlarged
in rickets, syphilis, and pulmonary osteo-arthropathy. '* Spade-shaped " hands
(with thickened tissues) are suggestive of myxoBdema, and largo, flat, ungainly hands
with osseous enlargement, of acromegaly and pulmonary osteo-arthropathy. The
*' olaw hand " {main en griffe) occurs as the result of injury or neuritis of the ulnar
and median nerves ; it is also seen in progressive muscular atrophy, syringomyelia,
and cervical pachymeningitis. Wrist-drop is very characteristic of lead palsy.

Cyakosis (Blusnbss) of thb Extbbmities. — Many people are bom with a
tendency to congestion — i.e., blueness or redness — of the hands and feet. They
appear to be the evidences of a vaso-motor instability or want of vascular tone. Such

1 Vide Illustrated Medical News, about 1890.

eo2

THE ESTREMITIES

[H«i

people ore speoiolly liable to cbilblMoa and othci kinds of erylbema ; in abort, they
might be called angio-neurotic subjoota. Slight degrees of oyanosis are revealed by
exaaiaing the nails and depresaing the nail tip. The canata 0} cyanoait were di«.
oussed in } 28. Epythromelalgia, " dead handa," gangrene, and Raynaud's diseMe
are referred to below. Cervical ribs have been the oasnal factor in some cues,

S 484. VaiioMe Tsini consist of dilatation and bortnosity of tho anpeificial vein*.
and are practically only met with in the legs, where their tortuous elevations produce
obvions and characteristic alterations in the contour of the limbs. Thay ooctir
chiefly in those who stand a great deal, and are more frequent in the female sex. and
espooially in those who have borne ohildren. Varicosity of the veins predlepoaea
to eczema and ulceration, and
severe hiemorrhage may ensue
frem their mpture. The Treat-
ment of varicose vems bdongs
mainly to the surgeon.

BlephantiuU TtianfiMtodM
(Fig. 116) is a rare condition
which is apt to be mistaken for
varicose veins. It consists of a
hyperplasia of the suboutaneona
tissues together with a vari-
cosity of the superficial veUis
which form loose msasee like
bunches of grapes beneath the
■kin. They are usually aasoci-
aled with a certain amount of
superficial telangiectasis (dila-
tation of venules) in the sldn
over and around the masses.

% VtS. (Bdems ot one limb
(localised dropsy) produoee
generalised swelling which pita
on pressure. The swelling due
to the rare condition elephan-
tiasis lympbangiectodes (see bO'
low] is of a much more solid
character. Apart frem infiam-
malory adema and an extenaiva
angio-nturofic adema ({ 464),
dropsy of one arm or one leg
always points to some obstmo-
lion of the main vein of tha
limb by thntmbosls within or
pressnte npon the vein.
(I) ThromboBx* (ooagnlatioti
within the living vessel] with or
without phlebitis (inflammation
of the vein) is not uncommon in
the femoral ot iliac vein in the leg, and the brachial in the arm. In addition to cedema
tJiere are pain and tendemesa at the seat of the obstructJon, and a history or evidence
at the time of some cause of thrombosis or phlebitis, such as phthisiB and other wasting
disorders, any of the acute specific fevers, injury or local extension (as boia an uloer).
The commonest example of thrombosis is pW^moaia dclem [or white leg), which ia
80 apt to come on after confinement, partly as a result of the hyperinotic condition
of tie blood (i.e., the exoess of fibrin-forming oonatituents) which is associated with
the poetpenl state, and partly owing to previous pressure on the veins within the pelvis.
LitUe can be done in the way of treatment beyond complete rest in the horitontal
poBitioQ, warmth applied to tho limb, and the administration of iron. Nothing will
lemove the obetmotion, but in course of time the condition is relieved considerably.

|«M] SWELLING OF THE LYMPHATIC GLANDS 603

if not oitogether, by the eatabliahment of oolUternl ciroulation. (ii.) <BdeDia m>y
also bo doe to prtMurt^ijxm a vein by a tamour, inch u enlarged gUnda in the axiU»
orelaewherB, tneoryBm. or other intni-tbonuiia groirth presung upon the Tcina coiniiig
from the wrm ; pelvio oelluiitis, oaroinotiw of the nteruB or bladder, bands of atUieaioa.
hydatid, or other intra-pelvio growth preEoiDg on the Terns of the leg. Local teuder-
uen is preaent in BMoeUtioD with cedema in thrombosis, aoarvy, and triohinosia.

BlepbautiMtl I^mphan^MlodM (Fig. 119} is a solid cedema, not pitting on pnMure
b uiy notable degree, affecting one l«g, ocoagiaiuklly one arm, or the soiotum, due
(o a UookiDg of the lymphatics of the limb. It is met with chiefly in tropical oountrie*

in ^iteiBOQs whose blood ooufauns the em-

bryo of tha filari» Banonifti. The adult
worm is believed to block the lymphatics, and
so produce the diseaae. 1% it, however, ooca-
sionoUy taet with in temperate climates in
persons whose blood does not reveal the
pMMite, and the cause of the blocking in
these cases is obscure.

i 4U. SwdUng 01 th« Lrmplistio GlMid* in
the neck, aiilln, groins, or elsewhere on the
surface of the body or limb* may be due to :

1. injuijr and septic or infective processes i

2, tuberculous disease ; 3, malignant disease i
4, syphilis; 6, acute speoiSc fevers; 6. leu-
kiemia; 7, Hodgkin's disease; 8, glandular
fever ; 9, pbgue ; 10, trypanosomiasis ;
11, Japanese river fever. The first three
arise in glands adjacent to some focus of
mischief, and the glandular swelling usually
remains localised ; iu the remainder all the
lymphatic glands tend to betsone affected.

1. Local injuries, septic sores, and atisoessel
give rise to enlargement of the neighbouring
lymphatic glands. When a patient com.
plains of pain and enlargement of the glands
in the groin, for instance, these may be due
to direct injury to or pressure on those glands ;
but one should always carefully inspect the
foot for abraded skiii aronnd the toe-nails,
through wluch dirt or stocking dye may have
been absorbed. Poat-mortau tenUdiet or
inoonlaljon from septicaniia oases are of a
much more virulent nature. Red streaks
along the courve of the lymphatics indicate
lymphangitis. The glands at the elbow and

axilla become acutely painful and tender, ltmph isqibc.

and they may rapidly suppurate. This is a '' iT)cks^iii''a^niBTi about forty ycin d

conservative process, for in this way the tta wbo had never been abioad.

septic virus is prevented (usually) from ex-
tending to the general circulation. If, however, the virus is too intense or the dose
be too large, general septicemia and death in a day or two is the result before
suppuration can occur.

2. Tvberouioat disease of the lymphatic glands, especially of the neck, is very
freqoent in children. The disease is usuoLy secondary to some other focus latent
or active, but is generally localised to one group of glands, and the process is slow
and chronic. It Is also recognised by the fact that the glands very soon become
matted together into one solid mass, which in due time, if the case be untreated,
undergoes caseation, breaks down, and leaves a oharaoteriatic ulcer.

3. Cancer ^ves rise first to inflammatory enlargement of the adjacent glands ;
later, tbe adjacent and distant glands becomes the seat of secondary cancer (% 41S).

604 THE EXTREMITIES [ { 467

Lymphosarcoma is a sarcomatous growth starting in the lymphatic glands. It rapidly
invades the surrounding structures, and the neighbouring glands.

4. Syphilis first affects the lymphatic glands in the neighbourhood of the chancre.
They aJe small, hard (shotty), painless, and only perceptible on palpation, but for
many years afterwards all the glands of the body, especially those in the groin, may
be discovered on careful palpation to be thus indurated. They never suppurate
with syphilis as they do with a soft chancre.

5. In most of the ociUe specific fevers there is, as in syphilis, a slight generalised
glandular enlargement. In those fevers which have a local manifestation, the throat
in scarlatina and diphtheria, for instance, the adjacent glands are first and chiefly
affected. In bubonic plague the enlargement is very great. In certain milder cases
of plague nothing but slight glandular swelling and a little fever occurs (pestis minor).
Such cases are often overlooked, but they may give rise to epidemics of pestis major,
or true plague. Rheumatoid arthritis is accompanied by enlargement of the glands
and spleen, especially in children.

6. In LeukcBmia there is a generalised enlargement, and the blood changes are
characteristic (§ 407).

7. Hodgkin's Disease starts with a swelling of one group of glands, which enlarges
paroxysmally, generally attended with corresponding paroxysms of fever. The
individual glands remain separate, painless, and may feel like a bunch of grapes.
Each gland may attain a large size. Sooner or later other groups of glands booomo
similarly involved (§ 408).

§ 427. The joints, muscles, bones, vessels, nerves, and constitu-
tional SYMPTOMS should be next investigated.

The joints may need investigation for tenderness, pain, heat, swelling, or redness,
and for loss of function or range of movement. The affected and the unaffected sidc^s
should be carefully compared. Slight degrees of fluid in a joint are often difficult
to detect. The active movomonts (those which the patient can make) and the passive
movements (those made by the doctor) should, with due consideration and caution,
be tested. Among the fallacies, paralysis, or muscular weakness is often simulated
by chronic joint diseases, and vice versa, and pain in the limbs from various causes
will often simulate a stiffness of the joint. Disease near a joint may be mistaken for
a diseased joint. Pain may be referred, e,g., in hip-joint disease pain is often com-
plained of at the knee. In neuritis pain may be referred to the joint supplied by the
affected nerve. X rays may aid. In acute joint disease the fallacies of epiphysitis
and acute osteomyelitis must be avoided. The presence of associated symptoms may
aid a diagnosis ; for example, tophi suggest gout ; purpura and subcutaneous nodules,
rheumatism.

The musolei may be investigated for tenderness, stiffness, or swelling. The in«
vestigation of paralysis, tonic or clonic spasm, or wasting, is given under diseases of
the nervous system (Chapter XIX.). We are here concerned only with pain, tender-
ness, or swellkig localised in the muscles ; it is the presence of these localised symp-
toms which helps us to differentiate muscular diseases from paralysis and other
diseases of the nervous system. To decide that the lesion is not in the bones or liga-
ments may be difficult ; if it be in the muscle, the pain is greater during active than
passive movement of the affected muscle ; if in the ligaments or joints, the pain is
about equal.

The examination of the bones belongs specially to the surgeon, but disease situated
in the bones may be evidenced by pain, tenderness, swelling, or deformity. They
often first come under the notice of the physician when pain is their only symptom,
and diagnosis presents considerable difficulty.

In the diagnosis of swkllimos oomnectbd with bones it is well to remember
the following data.^ Symptoms come on acutely with trauma, periostitis, osteo-
myelitis, and deep abscess ; slowly and chronically with caries, necrosis, ohronio
periostitis and osteitis, rickets, syphilis and tumour. In regard to physical signs
the diaphysis is mainly affected in acute and chronic inflammation, in sarcomatous

^ See also Mr. A. Pearce Gould's " Moments of Surgical Diagnosis."

f428] ROUTINE EXAMINATION AND CLA8SIFI0AT10N 606

ftnd other tumours ; the epiphysis in rickets, syphilis, and central sarooma. The
consistency of the swelling is soft in abscess and vascular sarcomata, hard in chronic
inflammation. As regards the mode and rate of growth, the swelling progressively
enlarges in inflammatory and malignant tumours, and is stationary in chronic
inflammation and benign tumours ; receding swellings are always inflammatory.

The Teiielf and nervef need examination when any of the symptoms indicate
their implication, as in er3rthromelalgia and some other conditions in Group I. below.
Pressure along their course may elicit tenderness, indicative of inflammation. The
symptoms and effects of peripheral neuritis are given in Chapter XIX., and embolism
of an artery or thrombosis of a vein in { 430.

The viiotta should be examined, particularly in acute joint diseases, which are
almost always the product of some blood disorder — e.g., the heart must always be
examined in rheumatic conditions, the kidney in gouty disorders.

Pyrexia and Oonititational Symptoms are present in a considerable number of
diseases of the extremities, particularly in the acuto joint and bone disorders, and
they may be investigated on the lines laid down in Chapter XV. Rigors and sweating
indicate a pyogenic process. Characteristic blood changes are found in several
diseases, notably glandular and septic processes.

PART C. DIAGNOSIS, PROGNOSIS, AND TREATMENT OF DISEASES
CAUSING SYMPTOMS REFERABLE TO THE EXTREMITIES,

§ 428. Routine Examination and Claariflcation. — ^As a matter of routine,
as in other cases, investigate —

First, the Leading Symptom, which in this instance is very often as
visible or palpable to the patient as to the physician.

Secondly y the History of the case, its mode of onset (acute or chronic),
and evolution in chronological order.

Thirdly, examine the affected LiBfB or limbs, their colour and con-
tour, the joints, muscles, bones, vessels, or nerves, as may be indicated ;
and, finally, examine the viscera and the temperature. The sensation,
movements, and reflexes should be tested in cases where nervous disease
is suspected. An X-ray examination is .useful in obscure cases.

If there is any visible abnormality in the colour of the hands or limbs,
turn to Group I., below, and p. 601.

If the symptoms point to joint disease, acute or chronic, turn to
Group II., p. 609 (Acute), or p. 618 (Chronic).

If the symptoms point to disease of the muscles, turn to p. 628.

If the symptoms point to disease of the bones, turn to p. 632.

If the symptoms point to disease of the nervous system, turn to § 552.

GROUP I. ALTERATIONS IN COLOUR OF THE EXTREMITIES.

This group comprises only the following morbid conditions whiqh may
be considered medical. Other alterations in colour or contour, such as
oedema of one limb and varicose veins, have already been referred to in
§§ 423 and 424. Pigment alterations are described in § 495. There remain —

1. Erythromelalgia and Acroterio Scleroderma.

2. Qangrene.

3. Raynaud's disease.

4. Dead hands.

6. Intermittent claudication.

6. Cyanosis, clubbed fingers, etc. (§ 423).

fl06 , THE EXTREMITIES [ {488

{ US. BryUuomalklglft (a t«rm fint used by Weir Mitchell') in a painful redneai
Knd swelling ocooning in parozyama, and sjmmetrioalty affecting both hands, aome-
timee the feet, and Mmetimes apreading to the arm» and legs. One side maj be more
affected than the other, but 1 have not seen any caaea in which both sides have not
ijeen involved to some extent.* The disorder starts intornutteoUy with tingling
and numbnesa in the eitremitics (aeropartfetheBia), and later on a painful rcdopsa
Bupervenes. The paroxysms are often determined, and always aggravated by hanging
the ^mbs down, and also by placing them in very hot or very oald water. They are
often worse when the patient lies down and gooa to sleep, and thus the night may be
badly distorbed. The pain and swelling are lessened by holding the hands over the
head, or raising the feet. There is no paralysis, but owing to the numbness ftnd
swelling the fingora cannot easily be bent. The swelting and redness afFect the whole
hand (Figa. 120 and 121) — not patches, as in chilblains, lupus, or erythema. Oh
this acoount the Diagnoeu is not difficult. In the cyanotic form of Raynaud'i diseatt
the symptoms start and prevail in one or two finger tips ; in erj^hromelalgia all the
fingers and the whole hand are about equally involved. Thickening of the sub-

aged aboot thirty.

cutaneous tiasues may ensue, and the paroxysms are apt to return even after long
intervals. It is a prolonged and very painful disorder, but it is not fatal, and is in
my experienoe to some extent amenable to treatment.

Etiology. — The female sex is far mora prone U> the disease ; out of thirty-aeveD
consecutive oases whioh I observed between 1900 and 1902 only two were moles.
It appears to arise more frequently between the ages of eighteen and twenty-fire,
and at the climacteric. The rheumatic, gouty, and hysterical diatheses piedispose
to the complaint, and the determining cause is, in my belief, some altered oondition
of the blood. It certainly occurs with erythrnmia and some cases of ehloroais. Several
cases wtiich I have observed have exhibited, concurrently with a severe paro^sm
of the erythromelalgio lymptoma, erythematous blotches on other parts of the body,
and severe " rheumatic " pains in the limha. The disease must, I think, be regarded

> FhUaddplua Midieal Tima, November 23. 1B72.

* See a clmloal lecture on this subject in the Laruel, June 1, 1902 ; and " Leotnree
on Hyat«ria," Olaisher, London,' 1909.

!S 480, 481 ] RA YNA UD'8 DISEASE 607

as a vaso-motor paralysis due to a toxemia ; associated probably with an inherent
instability of the vaso-motor centres controlling the ends of the extremities.

Treatment. — Bromides invariably relieve the condition for a time ; arsenic, stryoh*
nine, quinine, and other tonics are useful. Ergot sometimes does good. The general
health should be attended to, and particularly the digestion. I have tried salicylates
once with success. A weak descending galvanic current is the most efficient curative
agent in my experience.

Aeroteric Scleroderma (Hutchinson) or Sderodactrlia is a scleroderma affecting
the hands and feet, and sometimes the nose (see a case reported by the author, Pro-
ceedings of the Clinical Section, Roy. Soc. Med., March, 1909). in which the skin
is bluish and thickened at first, white and atrophic afterwards.

§ 480. Of Gangrene, necrosis, or death of part of an extremity, there are two kinds :

(a) In Dby Gakobbne the extremity becomes white and cold, then of an ashy
and black colour ; the part shrivels up, becomes dry and mummified. It is chiefly
met with among old people — senile gangrene — and is due to the gradual obliteration
of the lumen of the artery supplying the part, combined with more or less cardiac
enfeeblement. It is also met with in younger patients in Raynaud*s disease, and
in oases of embolic blocking of an artery. The artery is tender at the seat of the
embolism, and ceases to pulsate below.

(b) In Moist Gangrbkb the part becomes cold, purple, or mottled, and engorged
with blood. Blebs then form on the surface, and a bright red line separates the
dead from the living tissues. The dead part ultimately sloughs off, and leaves an
nicer. This gangrene is due to venous obstruction, the result of thrombosis, pressure,
injury, or inflammation. The gangrene occurring in diabetes is of the moist variety.
The treatment of both of these conditions belongs to surgery, but warmth, the posture
of the limb, and the administration of diffusible stimulants are points to be attended to.

{ 481. Baynand's Diseai e (Synonyms : Symmetrical Gangrene, Local Asphyxia
of the Extremities). — ^This disease, which was first described in 1862 by Dr. Raynaud, ^
is characterised by local vascular changes in one or more of the fingers, for the most
part symmetrically on the two sides of the body, resulting very often in gangrene.
Three types or stages of the disease have been described — a syncopal t3rpe, due to
vascular spasm, an asphyxial t3rpe, due to vascular dilatation, and a gangrenous type.

Sprnptoms. — ^Usually the first thing noticed is a pallor {local syncope) and numbness
of one or more of the fingers or toes, usually the corresponding finger or toe on both
sides, coming on in attacks, lasting an hour or more. This pale or sjmcopal stage is
generally followed by a reactionary stage of congestion and heat with swelling and
tividity (local asphyxia), in which the tip of one or more of the fingers or toes, or the
ears, may be of a dark purple hue. There is usually a good deal of pain. Sometimes
the pale stage is very definite, sometimes it is wanting, or it may be so transient
at to be unobserved. Occasionally the entire hands are involved. After a certain
number of these attacks gangrene occurs at the tip of one or more fingers or toes, or
of the ears, the dead becomes separated from the living part in the usual way, and
the ulcer that is left heals normally, but slowly. Cases have been recorded' of ex-
tensive multiple gangrene in which the patient has lost entire limbs in this way. The
attacks just described may be the only symptom, but in the majority of cases other
S3nnptoms of considerable pathological interest may be observed. In a certain number
of oases there is a generalised scleroderma, the skin having the appearance of being
stretched, and smooth, or sometimes cracked ; and in such cases all the fingers are pale
and dead-looking, and their entire substance becomes wasted. In a certain number
of oases er3rthematous blotches occur from time to time in different parte of the body,
which leave bruise-like stains. The patients are usually highly nervous, and prone
to emotional attacks. Transient attacks of hemiplegia and aphasia have been
observed, and attacks of paroxysmal hssmoglobinuria, all pointing to vaso-motor
irregularities in other parts of the body. Effusion into the phalangeal and other joints
may supervene, and may result in ankylosis.

1 " Th^se de Paris," 1862, a thesis written for the M.D. at the Paris University in
that year.

' Trans. Roy. Med.-Chir. Soc, Lend., vol. xii.

608 THE EXTREMITIES [ K 488. 488a

The Diagnosis is not usually difficult. In the earlier stages it is closely allied to
er3rthromelalgia, sclerodactylia, and to " dead hands/' but these affections are not
so localised to the finger's mds, are less severe, and never go on to gangrene.

Prognosis. — ^The disease runs a prolonged course of many years with a series of
attacks which become gradually more prolonged and frequent, and the patient gradu-
ally becomes more and more helpless. There are many degrees of severity of this
disease, ranging from what amounts to no more than a small localised syncope or
asphyxia to gangrene of the entire segment of a limb. It is a curious circumstance
which I believe to be uniform, that once a finger has become gangrenous the stump
does not become similarly affected later on. The subjects of this malady in a marked
form rarely reach old age, but usually die of some intercurrent malady.

Etiology. — ^The disease is more common in women, and especially those of a nervous
diathesis. It appears for the first time usually between the ages of fifteen and thirty.
Attacks may be brought on by chill or mental disturbances. The pathology of this
strange disorder is unknown, but it is undoubtedly a vaso-motor affection, and in view
of its symmetry b very probably a derangement of the local vaso-motor centres in
the cord. Endarteritis in the peripheral vessels has been described in a few cases.

Treatment. — The affected limbs must be kept warm with cotton wool, and the
patient protected from exposure to cold. The most efficacious remedy is undoubtedly
electricity, as originally suggested by Sir Thomas Barlow. The method I have
mentioneid under erythromelalgia may be employed, and as strong a current as
possible used. Sir Thomas Barlow recommends the constant current, but one case
under my care derived equal benefit from the interrupted current. Thyroid gland
and nitroglycerine have been used, and would certainly be indicated in the syncopal
type. The pain is intense, and may require morphia, which acts in a double way in
asphyxial cases by giving tone to the vessels.

§ 482. Dead Hands (Pallor of the Hands). — Many patients — but particularly
those who present other evidences of an inherent vaso-motor instability, and are
subjects of the gouty or rheumatic diathesis — complain that the hands or finger-Upe
" go dead," or white, like those of a corpse, and feel numb and cold. These attacks,
which rarely last very long, may happen in warm summer weather, without any
obvious cause, or consequent on anything which produces a nervous or emotional
condition. This vascular disorder appears clinically to be the converse of erythro-
melalgia, the fingers or hands being pale or shrunken instead of red and swollen.
It is akin to acroparsBsthesia and erythromelalgia, but it most resembles the slight
or early phase of Raynaud's disease. The Treatment should be directed to the diathesis
upon which they depend, combined if necessary with muscular exercise and electoioity.
These attckcks are not as a rule serious. They often depend upon oral or gastro-
intestinal sepsis.

§ 488a. Intermittent Olandication (Limping) is a rare condition pathologically
allied to angina pectoris, and if occurring in the leg is sometimes called angina cruris.
It is due to sclerosis of the arteries supplying the affected limb, usually of the smidler
branches, but sometimes of the main trunks. The symptoms come on when an
extra local supply of blood is required, such as during unusual exertion, or when the
circulation is at a disadvantage, as when the limb is kept dependent or is cold. The
symptoms are cramp-like pains in the extremity associated with pallor or blueness,
and the limb goes cold, numb, and powerless. During an attack the pulse of a distal
vessel (e.^., the dorsalis pedis) may cease to beat ; sometimes gangrene supervenes.

Treatment. — ^There are four indications for treatment : (i.) To treat the arterial
sclerosis. This is only effectual in the case of syphilis ; (ii.) to avoid undue exercise
or fixation of the affected limb ; (iii.) to avoid cold ; (iv.) to increase the peripheral
blood-supply by vaso-dilators such as nitroglycerine, by warmth, and by massage
or galvanism. Nitrites are useful, especially for acute pain.

§488]

ACUTE OOUT

609

OBOUP II, JOINT DI8EA8E8,

The methods of examination and exclusion of fallacies have already
been described. Arthritic disorders may conveniently be grouped into
acute and chronic :

Acute,

I. Acute gout.

II. Acute rheumatism.

III. Acute gonorrhoBal arthritis.

IV. Acute rheumatoid arthritis.
V. Fysemia.

VI. Acute specific fevers.
VII. Purpura, scurvy, hemophilia.
VIII. Traumatism.
IX. Extension from adjacent bone.

Ohronic,

L Chronic gout.
II. Chronic rheumatism.

III. Rheumatoid arthritis.

IV. Osteo-arthritis.

V. Spondylitis deformans.
VI. Gonorrhooal arthritis.
VII. Chronic septic processes.
VIII. Tuberculous synovitis.
IX. Syphilitic arthritis.
X. Hysterical joint disorder.
XI. Neuropathic joint disease.

(a) Acute Joi)U Diseases,

Acute joint diseases, a list of which has just been given, come on more
or less abruptly, and are as a rule attended by the local and general signs
of inflammation. Acute rheumatism is essentially an erratic polyarthritis
from the commencement ; acute gout usually afiects a single joint ; most
of the other causes start in one joint, but (excepting VIII. and IX.) tend
to a progressive involvement of others. It is worth noting that all the
acute joint disorders (traumatism being excluded) are due either to some
inicrobic process or to some other blood disorder. These facts emphasise
the necessity of investigating the constitutional symptoms, the viscera,
and the blood.

§ 433. I. Acute Qout — Grout is a diseased or disordered metabolism
associated with excess of uric acid in the blood, and characterised by
recurrent attacks of acute inflammation of the joints with deposition of
sodium urate. It is one of the oldest known diseases. Gout occurs in
acute, chronic, and irregular forms.

The Symptoms of an attack, or paroxysm, of acute gout are usually

preceded by gouty dyspepsia, heartburn, flatulence, and weariness after

food, fulness and tenderness in the epigastrium and liver, indentation of

the tongue, a bad taste in the mouth, and excessive secretion from the

fauces in the morning, scanty, high-coloured urine constantly depositing

urates, cardiac irregularities and intermissions in the pulse, restlessness

at night, and a tendency to catarrh of the mucous membranes on the

slightest exposure. The onset of an attack is usually very sudden^ often

in the middle of the night. It affects preferably one of the smaller joints,

and especially the metatarso-phalangeal joint of the big toe. The swelling

in a marked case is tense, shinmg, red, pits on pressure, and is acutely

tender, but suppuration never occurs. Other joints may become affected,

but the inflammation does not shift from one joint to another as in acute

rheumatism. Mild constitutional symptoms are present with pyrexia

610 THE EXTREMITIES [ f 4tS

(102°) ; there may be muttering delirium at night. The urine contains
less uric and phosphoric acid before the attack, and more during it, and
may contain a trace of albumen. An attack lasts from two to three
days or two to three weeks. After an attack the health is frequently
better than it was previously ; but the intervals between the attacks
gradually become shorter as time goes on, at first two or three years, then
one year, then six months ; finally the disease becomes chronic, and
permanent changes take place in the joint. Chronic gout and its associated
symptoms are described under chronic joint diseases, § 436.

Varieties, — (1) The symptoms of irregular or atonic gout consist chiefly
of dyspepsia and a variety of symptoms referable to various organs of the
body, supposed to be due to a deposit of gouty materials therein (see
complications below). (2) Retrocedent or suppressed gout is a term
applied to cases where the joint mischief suddenly improves coincident
with internal symptoms affecting the digestive tract, the heart or the
brain. Thus there may lie vomiting and diarrhoea, dyspnoea, arrhythmia,
even pericarditis, delirium and coma, or cerebral hsemorrhage. These
symptoms are often associated with chronic interstitial nephritis, which
is one of the consequences of gout.

The Diagnosis of acute gout is not difficult except sometimes from
acute rheumatism.

Table XXVI. — Diagnosis between Acute Gout and Acute

Rheumatism.

Acute GouL Acute Rheumaiiam.

In typical oases : i In typical cases :

Middle age ; male sex. Youth ; either sex.

Preference for smaller joints ; never i Preference for larger joints ; usually

wandering from joint to joint.

Swelling is usually red, tense, pitting
on pressure, acutely tender.

wandering from joint to joint.

Swelling is hot, but pale, tender only
on movement of joint.

Ears show tophi.

No tophi.

Fever may be slight or transient. Fever always marked and continuous.

Prognosis. — The duration of an attack or paroxysm — which is rarely
fatal in itself, depends mainly upon the age and constitutional condition
of the patient. When, however, symptoms of suppressed gout come on,
the case may end fatally with great suddenness. Gout tends to shorten
life mainly by the resulting kidney disease and cardio-vascular changes,
and the ultimate prognosis largely depends upon the condition of the
urine, which should be of good specific gravity and free from albumen.
Among the complications and so-called irregular forms of gout (1) chronic
interstitial nephritis is the most important. During an attack there is
generally a certain amount of albuminuria owing to congestion of the
kidney, or deposit of urate of sodium, but this passes off; Gradually,

§488] ACUTE OOUT 611

however, after repeated attacks, an interstitial fibrosis takes place in the
kidney, which from ttds association is known as the gouty kidney. Lithuria
or lithsemia (§ 249) is by some considered an irregular form of gout. Glyco-
suria occasionally occurs. Renal calculus occurs in persons of the gouty
diathesis who may have escaped joint symptoms. (2) Cardiac and cardio-
vascular diseases come next in frequency. The " gouty " heart is one
which is " irritable," acts irregularly, causing palpitation and pain, and
often great distress. Tachycardia is common. Gout is one of the chief
causes of angina. Various valvular lesions and a thickening and degenera-
tion of the arterial walls occur. (3) Bronchitis of a subacute or chronic
form is frequent, and in treating this the gouty condition must not be
forgotten. (4) Various gastric and hepatic derangements are frequent
in gouty subjects. Gastrodynia or an agonising pain in the abdomen is
sometimes caused by indiscretions in diet. (5) Eczema and other skin
diseases of an intractable kind supervene. Hot, itchy eyeballs, migraine,
and episcleritis are often present. Glaucoma and iritis also occur.

Etiology, — ^Among the predisposing causes of gout, age, sex, and heredity
are extremely important. (1) As regards age, the disease is rarely met
with under thirty, and the tendency increases up to the age of fifty. It
rarely starts for the first time over that age. (2) The disease is almost
confined to men ; if it occurs in women, the attacks are generally very
slight. (3) Out of 520 cases collected by Sir Alfred Garrod, 332, or nearly
two-thirds, were distinctly hereditary. The predisposition, like landed
possessions, is transmitted mainly through the male line ; but rarely it
may be transmitted by an unaffected female, and reappears in the sons.
(4) Lead in the system is also a strong predisposing factor; painters,
glaziers, etc., are very prone to gout and gouty kidney. (5) A plethoric
habit of body, with feeble circulation, is a predisposing factor. (6) Attacks
are more frequently met with in the changeable weather of the spring and
autumn. The exciting causes are (1) the use of alcohol, and especially
those forms which contain a high percentage of both sugar and alcohol,
such as port wine, brown sherry, Madeira, sweet wines generally, and
malt liquor. (2) Nitrogenous food in excess is credited with being able
to produce gout ; at any rate, it is commoner in butchers and meat eaters
than among vegetarians (compare remarks below). (3) Both of the fore-
going causes are more potent when combined with deficient exercise in the
open. (4) It is a curious and imperfectly explained fact that gout is very
rare in Scotland, at least among Scottish artisans. A possible explana-
tion of this exemption is that the beverage of the Scottish artisan i»
whisky, while that of the English workman is beer. An attack may bo
determined by (1) a debauch of alcohol, especially of certain kinds ;
(2) indigestion ; (3) a chill to the surface of the body ; (4) severe mental or
bodily fatigue ; (5) injury to a part, which will not only determine an attack
but also the particular part affected. There is, however, a tendency
for attacks to recur in the same joint.

612 THE EXTREMITIES [ {

The disoQssion of the pathology would be out of place here, but it may be repeated
that the clinical pheDomena are due to the presenoe of uric acid in abnormal amount.
Dr. Woods-Hutchinson ^ maintains that " the uric acid of gout, like the phosphoric
acid which invariably accompanies it, is merely a result and measure of the destmotiTe
metabolism of the nudeins of the body cells, chiefly (probably) of the leucocytes,
in response to the invasion of poisons or toxins, either organic or inorganic (lead,
phosphorus, alcohol, acetone). ... As most of the toxins . . . are of intestinal origin
or entry, diet in gout shovld he regulated solely with regard to the diminution of intestinal
fermentation and putrefaction," Hence, as he shows, meat in itself is not a cause of
gout, and in many gouty subjects does not cause gout except when taken together
with carbohydrates which decompose in the digestive tract.

Treatment during an attack resolves itself into dietetic and medioinal
measures. (1) It follows from what has just been said, that a low diet
of milk and farinaceous food, and complete abstinence from alcohol, should
be enjoined, unless the heart be fatty, when well diluted pure spirit is
the only form permissible. (2) A brisk cathartic with one or more grains
of calomel should be given at the onset, followed by frequent doses of saline
purgatives, such as Hunyadi Janos water, or Carlsbad. (3) Alkaline
carbonates (potassium, lithium, sodiiun) are very efficacious in promoting
the solution of uric acid. (4) Colchicum (combined with alkaline
carbonate) is regarded as a specific, and it may be given every four hours
(\\ 40 for first dose, then W]^ 12, or F. 88) until the pain is gone, then it
should be stopped. (5) Opium may be needed for the pain, but should
not be given if there be albuminuria or other evidence of renal changes.
(6) Local treatment consists of complete rest, wrapping the joint in cotton
wool, and the application of sedatives to the joint, such as lotions of
sodium bicarbonate 3iv., with laudanum 5ii. in Jx. of water. A very
comforting lotion consists of sp. vin. rect. 3iii. ; liq. amm. acet. 5iii.;
aq. rosflB oiii. ; aq. ad Jxii. When symptoms of suppressed gout come on,
employ eliminatory treatment promptly, stimulate if symptoms of collapse
follow, and apply counter-irritation (mustard, turpentine stupes) and hot
fomentations to the chest or abdomen as the case demands.

Treatment between the attacks — i.e., preventive treatment, resolves itself
mainly into a question of diet, and the treatment of gouty dyspepsia.
The dietetic treatment is of importance, as in chronic gout. All foods
rich in purin bodies are debarred, such as sweetbread, liver, stock soups,
and meat essences and extracts. The flesh of young animals is worse than
that of old ; beef is worse than mutton. Harmful vegetables are asparagus,
peas, and beans. Purin bodies also occur in tea, coffee, chocolate, eggs,
and mushrooms. Carbohydrates must be limited, because they consume
more oxygen and are apt to ferment in the intestines ; and the sugars and
fats, particularly the cooked fats, because they tax the liver too much.
It is probably for this reason that sweet wines, malt liquors, pastries, and
all sugar, and sweet and greasy dishes should be forbidden. Plain food
and abundance of pure water (to aid elimination) must be ordered. A
•*,uric*acid-free " diet consists of bread, macaroni, rice, and other cereals,

^ " The Meaning of Uric Acid and the Urates," by Dr. Woods-Hutchlnson» the
Lancet, January 31, 1903, p. 288.

§ 484 . ACUTE OOUT 613

biscuits, milk, cheese, nuts and almonds, dried fruits, and most vegetables.
The hygienic treatment consists of regular exercise in the open air, and
in aiding elimination. Among the remedies for the elimination of uric
acid the most yaluable in my experience is piperazine ; it may be given in
5 grain doses three times a day, or in the form of an artificial mineral
water. Lysidin, urotropin, and uricedin have also been recommended.
An occasional dose of mercury followed by a saline is useful. As regards
drugs colchicum is of little use, except in the subacute exacerbations,
when it may be given with large doses of potassium iodide until the pain
is relieved. Guaiacum, given in the form of the resin, 5 to 10 grains in
cachets, is a valuable preventive of the gouty paroxysms. Locally
blisters or iodine may be employed near the joints ; or alkaline lotions
(carbonate of lithium or sodium, 10 grains to the ounce). Massage, hot
air and radiant heat treatment is also useful (see Chronic Rheumatism);
Afineral waters (Carlsbad, Vichy, Hunyadi Janos, Friedrichshall) should
be freely used. Potassium or sodium bicarbonate has a beneficial effect
upon the alimentary canal, and it is a very good plan to order a small
teaspoonful in | pint of warm water to be drunJc every night and morning.
Some advocate the use of potassium instead of sodium salts, and cases
are reported which remained free of gouty symptoms when taking potassium
chloride instead of common salt with meals. Vbits to Bath, Harrogate,
Buxton, and Strathpeffer, in this country, are undoubtedly beneficial
because of the regulation of the life enforced there. Carlsbad, Royat,
Aix-les- Bains, and a number of other foreign spas are annually visited.
Qouty dyspepsia may be treated by the mineral waters just mentioned,
or on the principles laid down in Chapter X. The best tonics are nux
vomica, arsenic, and, if necessary, small doses of peptonate of iron.

§ 4d4. II. Acute Rheumatism (Rheumatic Fever) is an acute febrile
disease due to a microbic toxin circulating in the blood, with erratic
painful swellings of the joints and a marked tendency to disease of the
heart; running a prolonged course of many weeks if untreated, and
followed by a great tendency to relapse. It is a disease especially of child-
hood, when it is capable of many manifestations. The poison of rheu-
matic fever tends to affect not only the joints, but also all the fibrous,
serous and muscular tissues. The serous membranes of the joints, endo-
cardium, and pericardium (which, it will be observed, histologically
resemble each other) are the favourite situations of the inflammation.
Acute rheumatism, unlike acute gout, attacks several joints, usually the
larger ones — e.g., the knees, ankles, shoulders. In adults it occurs only in
a modified form, with polysynovitis as its most distinctive feature.

Symptoms. — (1) The fever, which may have been preceded by tonsMUis
for a day or two, comes on in the course of twenty-four hours, setting
in before or at the same time as the joints are inflamed. It is of a con-
tinued type (Fig. 122), usually remaining about 102° or 103® F. for some
days. The onset of any inflammatory complication in the pericardium
or elsewhere is marked by fever, pain, and sometimes delirium, which is

«U TUK EXTBEMlTIEti [ } 4M

otherwise extremdy rare in acute rheumatism ; in uncomplicated cases the
mind remains quite clear throughout. The usual accompaniments of
pyrexia are present — viz., the urine is scanty, highly coloured, loaded with
lithates, with an excess of uroa and deficiency of the chlorides ; the tongue
is coated, the pulse quick and bounding, usually over 100. The blood
exhibits considerable leucocj-tosis. (2) In adults there is a profuse
■pertjnration with a sour disagreeable odour and an acid reaction, but in
children this is unusual ; later on sudaminal vesicles are frequently seen.
Erythematous, purptiric, and other rashes occasionally appear. (3) The
two diatinguishing features of the joint lesions of acute rheumatism are
their wandering or metastatic character, and the absence of suppuration.
The eflusion into a joint is not very great ; first one joint is aSeoted, by
the next day another is involved, the lirst joint having almost renovered ;
finally several may be affected together. The joints are hot and swollen.

Fig. 1X2,— RHiminn Fetir.— Henry H , let. twenty-two; the oh»rt (bowi edner ol

ullcrUUa in redaclng the temperatDie until perlcuditlt ai>pean : tben the eoalroUtTK power
ol the dnig la leat.

and though not tender to the touch are acutely painful on the slightest
movement. The skin over the joints is either unaltered in colour or shows
a faint flush. (4) Pert- or endo-carditis are other manifestations of the
disease ; the pericardium may be the first serous membrane to be affected.
In 150 fatal cases analysed by Dr. P. J. Poyntcn, evidence of mitral endo-
carditis existed in 149. There is always some dilatation of the heart in
rheumatic fever, which is due to the action of the toxin on the cardiac
muscle. Myocarditis is commonly present, but rarely occurs as the sole
cardiac lesion. (5) Rheumatic nodulea occasionally occur. They are
small movable bodies, usually fibrmous, but may become fibrous. They
are generally symmetrically placed on opposite sides of the body and appear
on bony prominences and prominent tendons. The commonest places
to find them are about the elbows, knees, malleoli, occipital curved lines,
posterior spinous processes of the vertebra?, and knuckles. (6) Chorea is
a common manifestation in childhood, and is often the first sign of then-

§484] ACUTE RHEUMATISM 615

matism. (7) Pneumonia, pleurisy, iritis, periostitis, peritonitis, and
meningitis, all occur rarely. (8) In untreated cases the fever and local
inflammation may subside gradually in four to five weeks, and return again
after an interval lasting, perhaps, a few days to a fortnight. Even after
recovery the liability to recurrence is very great, and special care is needed.
In no other acute specific disease, excepting, perhaps, diphtheria, is the
blood so deteriorated in so short a time ; the patient shows grave anoBmia
during convalescence.

Two variations of the abo\e symptom -group are met with clinically.
In subaciUe rheumatism all the symptoms are milder, and may drag on
for months. " Growing pains " may be the only symptom complained
of by the child, and the cardiac infection may not reveal itself till years
later. Malignant rheumatic fever is a very serious form in which the
heart is mainly involved, the joints little if at all. An eruption something
like typhus may appear, and after a few days the temperature rapidly
rises and the patient dies.

The Diagnosis of rheumatic fever in the adult is not as a rule difficult.

Acute gout is distinguished by its sudden onset, and by the other features

mentioned in the table given above. Acute rheumatoid arthritis affects

chiefly the larger joints of the fingers (§ 4']8). The swelling is fusiform,

and does not subside under treatment by salicylates. Pyaemia (when

arising from some internal cause) may closely resemble rheumatic fever,

but in pyaemia the joint inflammation is not erratic, the pyrexia is typical,

accompanied by rigors, cerebral symptoms, and an enlarged spleen.

Gronorrhoeal arthritis usually affects the knees or the small tarsal or carpal

joints. The condition is more chronic, and there is a history of gleet.

Among the other diseases which sometimes have to be diagnosed are

dengue, which has a characteristic eruption ; trichinosis, in which the

pain and swelling are referable rather to the muscles, and are preceded by

gastric symptoms ; ulcerative endocarditis, in which the joint swelling is

absent, and the temperature intermittent. Osteomyelitis starting near

the epiphysis is a condition always to be borne in mind.

In infants, in whom it occurs rarely, its detection may be difficult,
as it may closely resemble infantile scurvy, which is known, however,
by the swollen gums and failure of treatment by salicylates. Syphilitic
epiphysitis and arthritis are known by the great local tenderness and
oedema extending beyond the joints, and the rapid improvement under mer-
cury. Rheumatism in infancy may also be mistaken for infantile paralysis.
Prognosis, — The disease is not dangerous to life when it attacks the
joints only, but if the heart is affected the prognosis is more grave. One
attack predisposes to future attacks. Other untoward symptoms are
hyperpyrexia and cerebral symptoms. An attack is grave in proportion
to the height of the temperature, the implication of the heart, and the
presence of cerebral symptoms. The latter, happily rare, are of the gravest
import unless accounted for by salicylates. The visceral manifestations
of rheumatic fever are more serious than the disease itself. The chief

616 THE EXTREMITIES [ § 484

of these relate to the heart, which should in all cases be examined daily
as a matter of routine.

Etiology. — ^Age is the most important predisposing factor, acute rheumatism being
almost confined to persons under twenty-five, the commonest age being between ten
and twenty. It is comparatively rare under ten and extremely rare in advanced
life. Dr. F. Langmead's investigations among school-children revealed the fact
that one in fifteen of those over seven years was rheumatic, and in 87 per cent, a cardiac
lesion developed. Males seem slightly more prone to the disease, and heredity plays
a considerable part. Among the determining causes may be mentioned exposure
to cold or chill, and fatigue. Acute rheumatism is apt to follow an attack of scarlatina
or chorea, just as these in turn may succeed an attack of rheumatism.

The clinical evidence on the resemblance of the symptoms of acute rheumatism
to those of septic infection — especially in its involvement of the endocardium and the
serous membranes — also supports the view of its being a specific infective disease. In
1900 Drs. F. J. Poynton and Alexander Paine ^ isolated a diplococcus from the blood,
exudates, and cardiac valves of rheumatic oases, which answered the tests of specificity.
This work has been corroborated by others, but still awaits general acceptance.

Treatment, — Absolute rest in bed is necessary. It is a good plan to
fold children in blankets. The diet is that for pyrexia (§ 391). As regards
drugs, salicylate of soda or salicin, first adopted by Dr. Maclagan, \a rightly
regarded as a specific. In most cases it abolishes pain and fever within
a week, but the treatment must be continued, else the symptoms will
relapse and the pain return. The drug must be given in large doses —
20 grains every two hours during the first day or two then every
four or five hours, till the temperature subsides or physiological
symptoms of the drug ensue — viz., headache, deafness, and buzzing in
the ears, albuminuria, or delirium. Danger-signals to be looked out for
as indications to omit the drug are vomiting, acetonuria, drowsiness, and
air-hunger — all indications of an acid intoxication.^ If initiated early
and before cardiac or other complications have arisen, this treatment
is certain to relieve (Fig. 122). In a few cases, however, especially those
in which the joints appear to be less involved than the heart, and those
in which the temperature is very high, salicylates may fail. Then anti-
pyrin or antifebrin are remedies of considerable value ; in any case, they
relieve the pain and may be good for this purpose alone ; morphia should
be avoided. Alkaline carbonates used to be given alone in large doses ;
they are still given, but in combination with salicylates. Dr. Lees recom-
mends very large doses of salicylate of soda, and avoids acid intoxication
by giving twice as much sodium bicarbonate as salicylate.^ It is essential
that the bowels should be opened before the drug is given, and at least
once a day during its administration. The joints should be swathed
in cotton-wool. An alkaline lotion containing opium (F. 35) may be used
if any local application is necessary. If, in spite of the salicylates, the
temperature remains high, quinine (10 grains every two hours till symptoms
arise) may be given. Drugs failing, and the temperature being ovei
104*5°, a graduated hot bath should be immediately given, as the con-

1 Dr. F. J. Poynton and Dr. A. Paine, ** The Etiology of Rheumatic Fever," the
iMficet, 1900, vol. ii., pp. 861 and 932.

2 F. S. Langmead, the Lancet, 1906.

3 Dr. D. B. Ix'es. Proc Roval Roc. Med., November, 1008.

§ 484 ] AC UTE RHE UMATI8M 617

dition of the patient requires prompt and energetic measures. If heart
complications arise, iodides should be given, and many recommend small
blisters (the size of a florin) to be applied over the left upper chest or over
the heart itself. During convalescence treatment is required to avoid
relapses and second attacks. The patient should always wear flannel,
avoid exposure, and be careful in his diet (see Chronic Rheumatism).
When school-children sufier with " growing-pains " or tonsillitis, a strict
watch should be kept on them, and rest in bed ordered if the heart show
any suspicious signs.

III. Acute GonorrhoBal ArthritiB (Gk>norrhceal Rheumatism) is an acute
arthritis resembling " rheumatic fever," due not to the rhemnatic diplo-
coccus but to infection by the gonococcus from the urethra during the
acute stage of gonorrhoea. It is far more frequently met with in the
chronic form described in § 441. If the disease arises in the acute stage
of gonorrhoea, the joint mischief resembles acute rheumatism in all respects
excepting : (1) Although the inflammation spreads from joint to joint
those first involved do not get better as the others become involved ;
(2) the temperature has more of an intermittent character than ordinary
acute rheumatism ; (3) it does not yield to salicylates, but runs a pro-
longed course of many weeks or months ; and (4) there is less tendency
to heart complications. The joints rarely suppurate, but the disease
is most intractable and may lead to extensive adhesions and distortions
of the various articulations. It is by no means unknown in children.

IV. Acute Rheumatoid Arthritis may start in a manner indistinguish-
able from rheumatism, but the joint swellings persist and become more
typically those of rheumatoid arthritis later (§ 438).

y. Pyeemia has already been described in § 383. In some cases of
acute general pyogenic infection the joints are not at all involved (septicaB-
mia), but in others of a pysemic type there is a marked tendency to a sup-
purative inflammation in and around the joints. It is differentiated
from other joint lesions by : (1) the swelling does not shift its position, as
rheumatism does ; (2) the joint may be red and show evidences of suppura-
tion ; (3) the constitutional symptoms are very characteristic, especially
the wide and irregular range of temperature and the rigors and sweatings ;
(4) some cause may be revealed in the shape of an internal or external
pyogenic focus (§ 384).

YI. Other acute specific diseases may — though less frequently than
the foregoing — lead to inflammation of joints. The joint disease can
be identified only by the presence or history of the disease which it com-
plicates. In adults pneumonia and enteric fever may be complicated
or followed by a suppurative affection of the joints, often with a fatal
issue. More rarely other acute specific fevers are so complicated. In
dengue joint swelling is often part of the disease; in Mediterranean fever
the joints are often affected. Cerebro-spinal meningitis is almost always
accompanied by synovitis. In children it commonly follows scarlet fever,
especially when there have been severe faucial symptoms. The^lesion

<^18 THE EXTREMITIES L § 486

may be suppurative. Measles, enteric, mumps, and influenza are rarer
causes in children. Synovitis sometimes follows the administration of
antitoxins (§ 454).

VII. There are throe remaining generalised disorders associated with joint trouble —
viz., Purpura Rheumatica, Scurvy, and Haemophilia.

§ 485. Purpura Bheumatica (S3monyms : Peliosis Rheumatica, Schonlein's Disease).
— In this disease a s3moviti8 resembling rheumatism is associated with a purpuric
or erythematous eruption.

Symptoms. — (1) Many joints are affected with considerable pain and swelling;

(2) the temperature varies between 100° and 103° F., the pyrexia usually preceding
the arthritis by a day or two, and being accompanied by more or less sore throat ;

(3) the eruption, which usually starts upon the legs near the joints, is of a purpuric,
urticarial, or erythematous character. It is attended by a good deal of aniemia.
The patient usually recovers in the course of a few weeks, but the disease is apt to
recur. The throat symptoms may lead to sloughing of the uvula. Males are more
affected than females, and at an age between twenty and thirty. The blood change
which underlies this condition is unknown.

In regard to Treatment, not much is known as to the appropriate remedies, but
it would be worth while trying large doses of calcium chloride. Anti-rheumatic
treatment is the line usually adopted.

Hbnooh's PuEPtTRA resembles purpura rheumatica very closely. It is chiefly
met with in children, is characterised by recurrent attacks of slight pain and swelling
of the joints, cutaneous lesions (for the most part erythematous and purpuric), gastro-
intestinal crises, and hsamorrhages from the raucous membranes.

In fcnrvy (§ 410) non-suppurative swellings occur beneath the periosteum near
the joints, but the joints themselves are not often affected. The disease is recog-
nised by the spongy bleeding gums, anasmia, and other symptoms of scurvy (q.v.).

In hamophilia (§ 411) the larger joints are usually affected. The joint lesion is
probably always due to the extravasation of blood or blood serum into the joint
cavities, and usually supervenes suddenly on a slight blow or exposure to chill. It
not infrequently recurs, and may ultimately lead to ankylosis. It is diagnosed mainly
by the history of hsemorrhages in the patient. The condition is met with for the first
time most often between the ages of seven and fourteen.

Vlli. Aonte Tranmatio Synovitifl is recognised by the history of an injury, though
one must bear in mind (1) that many constitutional processes, especially gout, are
lighted up by a very slight injury, and (2) that in childhood the history of a
traumatism may be wanting.

IX. Exteniion from epiphysitis or osteomyelitis (§ 446) or other bone disease in
childhood — set up very likely by injury — may produce acute inflammation in a joint,
and the serious nature of the condition may be overlooked unless the correct meaning
of the pyrexia and constitutional disturbance is appreciated.

(6) Chronic Joint Diseases.

Joint disorders which may be chronic ab initio come clinically under

eleven headings,

I. Chronic gout.
II. Chronic rheumatism.

III. Rheumatoid arthritis.

IV. Osteo-arthritis.

V. Spondylitis deformans.
VI. Clonic gonorrhoeal arthritis.
VII. Other forms of chronic suppurative arthritis.

VIII. Tuberculous joint disease.
IX. Syphilitic arthritis.

X. Hysterical joint affection, which is often in reality a muscular stiffening

and immobility.
XI. Neuropathic arthritis {e.g., Tabes, Syringomyelia, and Raynaud's disease).

§S 48e, 487 ] CHRONIC JOINT DISEASES 619

Clinioally many of these joint diseases resemble each other very closely, both in
their physical signs and their history, and many cases are met with which it is almost
impossible to place definitely under one or other disease. Moreover, in their pathology
we find the same resemblance, for with the possible exception of hysterical and neuro-
pathic arthritis they are all duo to a blood change of miorobic or metabolic origin.

§ 486. I. Chrome Goat usually supervenes upon a succession of acute
attacks (§ 433) ; occasionally it is chronic or subacute from the beginning.
The joint is stiff and painful on movement, is very tender, sometimes red,
and sometimes masses of urate of soda (chalk stones) can be seen through
the skin. The patient, who is usually a male over middle age, suffers
also from gouty dyBpepsia, irritability of temper, and frequent subacute
exacerbations of joint trouble. Tophi are usually present. They consist
of nodules of sodium biurate, analagous to the deposits in the joints,
and are commonly situated in the cartilage of the ear, near the helix,
and in bursal sacs. The urine may contain a little albumen from time
to time. The arteries are generally thick, and there is a marked tendency
to high arterial tension.

The Diagnosis between chronic rheumatism and chronic gout is by
no means easy. In an infirmary, where a large number of both diseases
in the chronic form are always to be seen, it is usually impossible to classify
more than one-third of them. In general terms, chronic gout attacks
the smaller joints, the patient is of a plethoric type, and there are con-
current symptoms such as tophi in the ears, interstitial nephritis, or the
history of typical paroxysms, which give us some indication of gout.
The serum test of acute gout is not of great assistance in the chronic
disease (see also table, § 437).

The Prognosis of chronic gout is more serious than that of chronic
rheumatism, though in both the same crippling of the joints occurs.
Interstitial nephritis (granular kidney) is almost sure to supervene sooner
or later, and the prognosis mainly depends on three factors : (i.) the
condition of the kidneys ; (ii.) the degree of arterial tension ; and (iii.) the
condition of the heart, especially of the heart wall. The complications
in addition to those mentioned under Acute Gout are (1) bronchitis ;
(2) iritis and scleritis ; and (3) deposits of urates not only in the con-
junctiva but in any other tissue of the body. Urethritis may occur in
males ; stone is not uncommon, and sometimes glycosuria is seen. The
patient may eventually die with ur»mia, pericarditis, pleurisy, peritonitis,
meningitis, or apoplexy. The TrecUment is described under Acute Gout.

§ 487. II. Chroiiie Rheumatism is a common affection of the joints.
The disease may follow one or more acute attacks, or as is more usual
oome on insidiously as a chronic affection from the beginning. There
are some grounds for believing that chronic rheumatism is pathologically
distinct from acute rheumatism. The capsule, ligaments, and tendon
sheaths are thickened. The joint is stiff and creaks with adhesions, is
generally more or less swollen, and sometimes tender. Sometimes many
joints are affected synmietrically ; sometimes only one is affected. Ulti-
mately the joint may be considerably distorted, but not disorganised,

620

THE EXTREMITIES

[§4S7

there being a tendency towards adhesions and fibrous thickenings. When
the hands are affected they are in time permanently deformed. The
general health, in many cases, is not disturbed, and there is no tendemcy
to either heart or renal affections ; though there is a certain amount of
anaemia and a variable degree of pain. The disease is never fatal.

The Diagnosis from chronic gout is sometimes very difficult. Many
hold that it is the same disease as rheumatoid arthritis.

Table XXVII. — Table of Diagnosis.

Chronic Khmtmaium,

Chronie Qaut.

Rheumatoid Arthritit.

OtUo-arthritu.

Either sex ; middle Generally male sex ; Chiefly female sex ;

life or over.

Poor and debilitated.
Insidious onset, un-
less following rhea-
matio fever.

over forty.

nsuaUy twenty to
forty.

Females more than
males ; forty to
sixty.

Rich and plethoric More common in the More common In poor
generally. Histonry j poor. Onset acate, and debilitated.

sabaoate, or in-
sidious. Constita-
tional symptoms
present.

of sadden onset and i
acate attacks with
severe pain. Skin '
over joints red, -
swollen, and oede- <
matous. j

Onset, insidious; ;
course, progressive. ,
No constitutional
symptoms.

Generally polyarticu-
lar. Temporo-max-
illary Joint not af-
fected.

Only one Joint affected Generally polyarticu-
at first ; usually the lar. Temporo-max-

Thickening of tendons
and ligaments ; no
bone changes.

metatarso - phalan-
geal of the great toe.

illary Joint often
affected. Spreads
from the smaller
Joints to the larger ;
terminal interphal-
angeal Joints usually
unaffected.

Polyarticular or mono-
articular. Temporo-
maxiUary Joint af-
fected; terminal
interphalangeal
Joints usually af-
fected.

Deposits of urat« of < Spindle • shaped
soda round the
Joints. I

en-

Radial deviation of
largement with ul- terminal phalanges,
nar deviation and : Lipping and osteo-
later some fixation. ' phytes marked.
No lipping or osteo- [
phytes. I

Apart from arthritic heredity the Etiology is obscure. The patient is
generally past middle life, unless chronic rheumatism has followed acute
attacks, when the patient may be younger.

Treatment,— DivLgs are not nearly so potent in chronic as in acute
rheumatism ; among those which may be found useful are potassium
iodide, guaiacum, quinine, alkab'es, sarsaparilla ; and in cases with much
weakness and ansemia, cod-liver oil is excellent. Local treatment is often
more useful — e.^., iodine, blistering, turpentine or other liniments, actual
cautery, massage, Scott's dressing, or the application of oleate of mercury.
Some cases have responded to treatment with parodontal vaccines, although
not (apparently) affected with pyorrhoea alveolaris. lonisation gives
good results. The diet is of considerable importance. The patient
should avoid sugar and alcohol of all kinds, excepting in very debilitated
states, when a small quantity of spirits may be taken. What is known

§ 488 ] RHEUMATOID ABTHRITI8 621

as the Salisbury treatment is certainly very efficacious in some cases.^
One of the most satisfactory methods of treating chronic rheumatism
and many other joint affections is the application of hot air. This may
be given in the form of Turkish baths, or in the form of superheated air
as given in the Tallerman method,^ or by radiant heat. On the same
principle passive h3rpersemia of the joint, induced by bandaging firmly
below and above, has given good results. Baths of many different kinds
have been used, chiefly sulphur and alkaline baths — see F. 1, 3, and 6.
Change of climate does much for those who can afford it. Wintering
abroad to avoid cold and dramp is undoubtedly most beneflcial, especially
in a climate like Egypt. Climatic treatment may be combined with
baths, as at Aix-les-Bains, Baden-Baden, Buxton, Bath, Carlsbad, Con-
trex6ville, Harrogate, Mont-Dore, Strathpeffer, etc.

§ 488. III. Rheumatoid Arthritis. — The terms Eheumatoid Arthiitis,
Osteo-arthritis, Rheumatic Gout, and Arthritis Deformans have been
used loosely as synonyms, whereas the first two are separate clinical
entities and rheumatic gout is an inaccurate term. This opinion was
clearly expressed at a discussion at the Medical Society of London in
1906, which was opened by Dr. A. E. Garrod,^ and the classification then
made will be adhered to in the following descriptions.

Rheumatoid arthritis is a general disease, producing synovitis and
peri-arthritis, as shown by swelling and pain in the joints. It tends to
get well, often after a protracted course, but leaves, not uncommonly,
considerable deformity and crippling. It manifests also symptoms of
constitutional disturbance.

Symptoms, — The onset may be acute, subacute, or chronic. In the
first form the condition closely resembles acute rheumatism at first, but
the joints prove intractable to the action of salicylates, and later assume
the typical characters. In the subacute variety the joints are rapidly
affected, but show only slight swelling at first, whilst the temperature
is but little raised. The chronic form begins insidiously in one joint,
and spreads s'owly.

1. The joints usually affected first are the proximal row of the inter-
phalangeal joints of the fingers, and the metacarpo-phalangeal joints ;
next the wrists, ankles, and knees ; then the shoulders, and last of all the
hips, so that the progression of the disease in the joints is from the peri-
phery. The lesions are symmetrical. The temporo-maxillary and verte-
bral joints are especially liable to be attacked. The distal interphalangeal
joints are usually spared. During the active stage the joints are painful,
tender, and swollen, and somewhat limited in movement. The swelling

^ A very satisfactory case of this treatment is published in the Lancet, 1893, vol. ii.
p. 133.

2 This is applied in the following way : The limb is placed in a specially-made copper
chamber made to fit the limb, and the temperature in the interior is ^adually in-
creased up to 250° to 300° F. Each application lasts about twenty mmutes. The
anodyne effect is said to be remarkable, and permanent benefit is reported in some
cases.

3 Trans. Med. 8oc. Lond., 1906.

622 THE EXTREMITIBS [1*W

is fusiform, due to the fact that the lesion is a combination o£ aynovitie
and peii-arthritis t and there are neither lipping of bone or oateophytea
to be felt, nor can grating be elicited. If the active stage is of long dura-
tion, this may be followed later by very marked limitation of movement
and deformity, due to the formation of adhesions within and around the
joint, and to the secondary contraction of muscles. In severe cases
paitial dislocation or ankylosis may occur. The most common dis-
placement is that of ulnar deviation of the fingers (Fig. 123). The muaclea
above and below the affected joints are conspicuously atrophied, to a
much greater extent than could be explained by disuse. The tendon
reflexes are increased.

2. Subcutaneous nodules are sometimes present. Usually these are
in the form of flat masses in burste, especially the olecranon bursa ; but
more rarely they resemble the nodules of rheiunatism, differing from them
in being more permanent and occasionally tender.

t"l(. 123.— RUBDIUTOIB

3. The skin is glossy, atrophic, and apt to become parchment-like on
the backs of the hands and fingers, which are often cold. Pigmentation
is common, and may occur as circumscribed spots like freckles, or as
diffusa spreading patches. It occurs especially on the face and neck,
and on the backs of the wrista and forearms, but may be general. The
forehead may shine like burnished bionze and various tints of yellow and
brown are seen by reflected light at different angles. A brawny oedema
of feet and legs may be present, independent of cardiac or renal disease.
i. The axillary and inguinal glands are not uncommonly swoUen.
5. Constitutional symptoms. There is usually some fever dniing the
active stage, the temperature varying from normal to as high as 102° or
\0'i° F. The pulse is nearly always quickened, and may be from 90 to
100 for years. It may be persistently 120. The general nutrition is
impaired, and the patient is usually pale and depressed.

The Diagnosis is considered in the table on p. 620.

5 489 ] RffE UMA TOW A RTffRITIS—OSTEO'A RTHRITIS 623

In children oertain forms of arthritis occur which resemble the lesions of rheu-
matoid arthritis in adults. The multiple arthritis described by Dr. G. F. Still (Still^s
disease), associated with pallor, fever, wasting, and enlargement of the lymphatic
glands and spleen, differs from the description given above only in the frequency of
affection of the glands and the splenic enlargement. It is probably rheumatoid
arthritis modified by the age at which it occurs.

Prognosis, — It should be clearly recognised that rheumatoid arthritis
is not a progressive disease, but runs a definite course. The course,
however, may be very protracted, and relapses frequently occur. The
outlook is serious because of the consequent crippling and deformity.
The longer the active stage, the greater is the crippling. It is rarely fatal.

Etiology, — The disease may occur at any age, but is most common
between twenty and forty. Females are more often affected than males,
in the proportion of about three to one. A lowered resistance of the
individual frequently precedes an attack, which may in this way follow
acute infections, especially influenza, or overwork and anxiety. Dental
caries, and pyorrhoea alveolaris, septic conditions of the nose and throat,
and ulcerating piles are among the conditions which are said to act as in-
fecting foci. Some regard the disease as due to absorption of toxins from
the alimentary canal.

Treatment, — During the active stage rest is essential, enforced by the
aid of splints if necessary. At the same time, when the pain has diminished,
the muscles should be massaged, to counteract wasting and fixation.
The diet, according to Dr. A. E. Garrod, should be abundant and nourishing.
When no longer active, spa treatment is beneficial, especially combined
with douches and massage. Such is obtainable at Bath, Buxton, Harro-
gate, and Aix-les-Bains. Brine baths, vapour, hot air, and electric
baths also relieve. Bier's method of passive hypersemia, induced by
applying a firm elastic bandage above the joint for a few hours, several
times a day, is sometimes useful. If the joints are painful, the local
iodine vapour bath, as reconamended by Dr. Luff, almost always relieves.
The joint is washed and dried, and then the skin over it is painted with
tincture of iodine. Over this a thin layer of butter muslin is placed.
A linseed poultice is applied outside this, and the part is swathed in cotton-
wool. Drugs, — A combination of guaiacol carbonate and potassium
iodide in gradually increasing doses up to the limit of toleration, and per-
sisted in for several months, is the most valuable medicinal remedy.
Salicylates and aspirin relieve painful joints, or guaiacol, or linimentum
potassii iodidi cum sapone, locally applied. Equal parts of guaiacol,
menthol, and linimentum camphorse painted on is very useful. Ionic
medication, using potassium iodide, may be tried. Any possible focus
of infection such as oral sepsis should be attended to.

§ 439. IV. Osteo-arthritis is a chronic degenerative disease of joints,
progressive in character, and occurring chiefly in the elderly.

Symptoms, — The special features of the joints are as follows : The ends
of the bones are thickened and lipped. The synovial membrane is also
thicekned, and thickened fringes can be felt, in some of which cartila-

624 THE EXTREMITIES [ §

ginous bodies are recognisable. These may be pedunculated or free,
fonning the so-called melon seed bodies. Bony outgrowths or osteophytes
aie formed, often in great quantity, so that if the joint is moved, scrunch-
ing or grating is audible, and by their interlocking, movement is much
restricted. True ankylosis rarely occurs. The joint is often distended
with fluid, as are also the bursae, around it. Sometimes the encysted
collections of fluid near the joint are imconnected with burssa, but are
lying in spaces bounded by muscles and areolar tissue. Pain is not usually
severe, but the joints often feel hot and tingling, and occasionally numb.
In severe cases considerable deformity results from absorption of the ends
of the bones, so that shortening or displacement is produced. There is
no constitutional disturbance in this disease. Muscular atrophy occurs,
but is less marked than in rheumatoid arthritis, and does not lead to the
same crippling by contracture.

The cQsease manifests itself in several forms, and may be localised
or general :

1 . Heberden^s Nodes form the conmionest and best known variety. These
are bony outgrowths, which occur at the sides of the distal interphalangeal
joints. They are usually painless, but may be painful, and produce
nimibness and tingling in the fingers. Little bursal swellings occasionally
accompany them. In advanced cases the terminal phalanges are bent
acutely toward the radial side. The hands are symmetrically affected.
This condition may exist alone as evidence of osteo-arthritis, but often
accompanies other varieties.

2. The Carpo'tnetacarpal Joints of the Thumbs are not infrequently
affected alone, or with Heberden's nodes. The joints are loose and grate,
and the bones can be felt to be lipped.

3. The Knees are frequently affected in women at the menopause.
Pain and stiffness is noticed on walking or going downstairs, and the knees
give way, letting the patient down. If the joint be moved when the patella
is depressed by pressure with the thumbs, a fine velvety scnmch can be
felt and heard. Later the joint assumes the ordinary deformity.

4. The TemforO'tnaxUlary Joints may be first or solely affected, and
the osseous outgrowths may lead to locking so that chewing is impos-
sible. This joint is not so often affected as in rheimiatoid arthritis.

5. The Hip-joint of Elderly Men, — This is the most important local
form of the disease, since it leads to considerable crippling. It is usually
unilateral. There are pain and rigidity of one hip-joint with difficulty
in adduction. The pain is felt most severely in the groin, but may radiate
down the front of the thigh to the knee. From sciatica, with which it is
often confused, it is distinguished by the position of the pain, and the
fixity of the joint. Wasting may occur later, but is limited to the buttock
and thigh. The limb may be shortened. It occurs chiefly in men over

fifty.

6. The Oeneralised Form, — In this condition most of the joints in
the body may be attacked, including those of the spine. In the hands.

§§ 440, 441 1 OSTEO-ABTHBITIS 626

the distal interphalangeal joints and the carpo-metacarpal joints of the
thumbs are usually selected, and show the characteristic grating and
lipping, not the fusiform swelling of rheumatoid arthritis.

Prognosis, — If treated early, temporary improvement may occur, but
speaking broadily, the disease is progressive. The form occurring in the
hip- joint of old men is very intractable, but that in the knees of women
at the menopause more remediable. The crippling is not great, but
patients with the joints of the lower extremities affected will often be
afraid to get about, because of the fear of the knees giving way.

Etiology. — It occurs most often in women between forty and sixty
years of age. It is doubtful whether the joint lesions are in any way
specific, since similar changes occur as the result of traumatism of pro-
longed pressure, as by a tight boot, in haemophilia from repeated haemor-
rhages, and in tabes dorsalis and syringomyelia.

Treatment, — The diet should be plentiful and nourishing. Local treat-
ment, by means of hot baths, hot air, or electric baths combined with
massage, is very useful. The douche-massage treatment sometimes
produces great improvement. The joints should be moved, but not
forcibly. These forms of treatment are often more satisfactorily complied
with at spas, such as Bath, Harrogate, or Buxton. In the early stages
iodide of iron and arsenic should be freely employed, and are often very
beneficial. Aspirin relieves the pain. The local iodine vapour bath
reconamended by Dr. Luff (vide swpra) is valuable if pain be present.
Ionic medication with potassium iodide may be tried.

§ 440. V. Spondylitis Deformans is a disease formerly classed under rheumatoid
arthritis, but now recognised as a morbid entity. The vertebral column and th(*
shoulder and hip joints are most often affoct<Kl.

Symptoms. — The spine may be quite rigid, so that the name " poker back " is
aptly applied. This is due to a s3mostosis of the vertebrse and ossification of the
intervertebral ligaments. A similar change at the hips and shoulders may produce
fixation, partial or complete, of these joints also. There is marked kyphosis of the
upper part of the spine. The chest is flattened, and the breathing is sometimes
entirely abdominal, due to fixation of the costovertebral joints. Nipping of the
nerves at their exit between the vertebrse may lead to referred pains around the chest
or abdomen, areas of impaired sensation, paraesthesia, and local atrophy of muscle.

Etiology. — It occurs chiefly in adult males, but has been described in children.
Three children in one family have been attacked. Syphilis, gonorrhoea, and injury
have all been suggested as the cause.

TreatmeTU is symptomatic, and on the same lines as that for osteo -arthritis.

§ 441. YI. GonorrhoBal Rheumatism (Synonyms : Gonorrhoea! Arthritis,
Urethral Arthritis) is a synovitis associated with a gonorrhoeal discharge
resembling chronic rheumatism in some respects, chronic pyaemia in others.
An acute form has been referred to on p. 617, but the disease is nearly
always chronic. In this, the chronic and commoner form, the joint affection
comes on insidiously during the gleet (often about the fourth or fifth week).
According to surgeons who see many of these cases, it is particularly apt
to supervene in those cases of gonorrhoea in which the prostatic portion
of the urethra is affected, and the extreme vascularity -of that part lends
probability to this view. When the joint becomes involved, the gleet

626 THE EXTREMITIES I § 441

sometimes disappears, a circumstance which may give rise to an error
in diagnosis. In the chronic variety there is only slight elevation of
temperature of an intermittent or hectic kind ; but the general health is
always more or less disturbed, and may be so greatly that the patient
becomes anaemic and emaciated. Some say that the affection is usually
monarticular, the knee being its favourite seat ; but in all the cases I have
seen many of the joints have become progressively involved. It never
shifts its position, but is progressive. It is apt, moreover, to attack
many of the joints usually spared in other diseases, such as the sacro-
iliac, stemo-clavicular, and temporo-maxillary, and to settle down the
smaller joints of the carpus or tarsus. The affected joint becomes swollen,
stiff, and tender, and gradually becomes permanently damaged, resulting,
perhaps, in ankylosis or dislocation. The fibrous tissues also are often
affected, especially the plantar fascia ; pain in this position or in the tendo
Achills is an important diagnostic feature of the disease.

For the Diagnosis one has to rely mainly on the history of gonorrhoea,
the inveterate character, the tendency to ankylosis, and the fact that it
is wholly unrelieved by salicylates.

The Prognosis as regards life is favourable, but complete recovery
cannot occur till after months of treatment. It is more hopeful in younger
people and in attacks of recent date. The heart is seldom affected, but
there may be pleurisy or iritis, and in rare cases the meninges have become
affected, with fatal result. The probability of cure depends greatly
on the curability of the urethritis, which with modem methods is more
feasible.

As regards Etiology, both men and women may be affected. It has
been definitely shown that the gonococcus may be present in the joint,
with or without strep to- or staphylococci. Special exposure t.o chill
during a gonorrhoea will sometimes determine the disease.

Treatment. — The first indication is to cure the urethritis. This is some-
times extremely difficult, especially when, as generally happens, the gleet
takes on a fresh development after its temporary disappearance. The
gum resins and ordinary injections are useless in most cases. Urotropin,
helmitol, and other urinary antiseptics may be tried. A course of local
applications to the urethra is usually required. For this purpose silver
nitrate, argyrol, protargol, and potassium permanganate are useful.
For the joint mischief one of the most useful applications is Scott's dressing
with ung. hydrargyri or oleate of mercury ; and the treatment suggested
for chronic rheumatism may be tried. The late Mr. Christopher Heath^
treated cases with belladonna and glycerine applications, and 5 grains
of sulphate of quinine every six hours internally, and stated that the
patients were usually better in three or four weeks. Bier's treatment
by hypersemia has given good results. Iodide of potassiimi in large doses
is reconmiended by some. A sea voyage is, in my experience, one of

1 The Lancet, November 25, 1899, p. 1467.

§448] TUBEMCUL0818, HYPHILIS, AND HYSTERIA 627

the most efficacious remedies. Climatic and bath treatment is also
advantageous. It is of the greatest importance to improve the patient's
general nutrition. The patient should avoid thereafter any possibility
of a fresh attack of gonorrhoea, as this would most certainly be followed
by a rectirrence of the joint symptoms. Surgical treatment by irrigation
of the joint in severe cases is often efficacious. Inoculation with gonococcus
vaccine has yielded good results, and should be tried.

VII. Other forms o£ Ohronio Septic Arthritis. — Chronic infective arthritis (chronic
pyiemic arthritis) is not a form of chronic joint affection generally recognised by
authors, so far as I am aware, unless the chronic form of gonorrhoeal rheumatism
is so regarded. A case which I had under my care for many months (and one other
of a similar nature) is described and illustrated in § 384, which is best explained
on the supposition that the joint mischief was due to secondary infection from an
internal pyogenic focus — namely, in the appendix. Cases of arthritis have been
recorded which occurred during convalescence from dysentery (see § 435 VI.).

§ 442. Tuberculosis, Syphilis, Hysteria, Tabes Dorsalis, and other
nervous disorders also aSect the joints.

Vni. Taberonloiui Joint Disease. — Tuberculosis affects chiefly the synovial mem-
brane, but it may commence in the articular ends of the bones. This is par excellence
the mon-artioular joint disease of children.

Symptoms, — The onset is insidious, though not infrequently the symptoms date,
or are supposed to date, from an injury. The favourite situations are hip and knee-
joint, though any joint may be affected. The child may complain of slight pain,
which gives rise to limping, for weeks or months before anything is apparent. Gener-
ally the disease is in the knee, but sometimes it is in the hip, although the pain may
still be referred to the knee, one nerve supply of which is also a branch of the obturator
nerve. By-and-by the affected joint swells ; it is pale, and has a pulpy or doughy feel
beneath the finger, and fluctuation may be felt. If untreated, the case goes on to
abscess formation. The constitutional symptoms consist of an intermitting pyrexia,
and general debility which are present even from the very beginning.

The Causes are the same as those mentioned under phthisis. The symptoms may
date from or be first noted after an injury. The disease nearly always attacks children,
though a more destructive form of tuberculous joint mischief does occur in advanced
life. It may last for many years, and the prospect of recovery depends very much
upon the stage at which it first comes under treatment. If neglected, extensive
destruction of the joint may occur, and very frequently tuberculous mischief is found
in other organs. The TreatmetU is mainly dealt with by the surgeon, but a good deal
can be done in the early stages by rest, fresh air, and cod-liver oil.

IX. Syphilitic Joint Disease. — In the secondary stage of syphilis there may be
(i.) a subacute arthritis with redness and pain, or (ii.) an indolent hydrarthrosis, with
little pain. In the tertiary stage of syphilis the differential features of the arthritis
are : (1) One or several joints may be affected. The 83010 vial membrane may bo
attacked, leading to a doughy swelling ; or the ligaments or cartilage. (2) The joint
manifests no signs of acute inflammation, but there is occasionally some effusion.

(3) The pain is very moderate during the day, but subject to nocturnal exacerbations.

(4) Other evidences of syphilis are generally present. (6) The condition is very
ohronic, and is only partially amenable to iodides. It may occur in children.

A PsBUDO- Paralysis of Syphilitio Origin occurs in infants, due to the separa
tion of the cartilage from the diaphysis, and is apt to be mistaken either for joint
disease or for infantile paralysis. The affected part is, however, acutely tender.

X. Hysterical Joint Disorder usually affects the hip or the knee, and it often dates
from some trifling injury. The joint is fixed, tender (often more tender to light
touches than to deep pressure), and sometimes swollen, and the local temperature
of the joint may also be raised. Sometimes there are no physical signs referable
to the joint at all. The loss of function may be entirely due to muscular rigidity,
and in the case of the hip- joint the condition may very precisely resemble (mimic.

628 THE EXTREMITIES { § 44S

as Sir Jas. Paget ^ says) tuberculous disease of this joint. Thx& DiagnoaU, which is
often extremely difficult, rests mainly on (1) the absence of evidence of serious disease
in the affected joint when examined under chloroform ; (2) the disproportionate loss
of function ; (3) the patient being a female, and the subject of other manifestations
of the hysterical diathesis. Intermittent hydrarthrosis possibly comes under
this heading. The joint swells at periodic intervals which the patient can foretell
almost to a day.

The Treatment should be mainly directed to the hysteria (q.v.). The joint mischief
may sometimes be cured by chloroform anaesthesia ; on coming rotmd the patient
finds that she can use the joint, and continues to do so. In the author's view^ these
cases are due to a vascular change in the synovial membrane, probably of vaso-
motor or toxic origin, albeit slight, and perhaps temporary and evanescent. Many
cases of undoubted hysterical joint disease are amenable to salicylates, or alkaline
carbonates on the one hand, or to bromides or vaso-motor remedies on the other.

XI. Venro-tropbic Arthritis (Synonyms : Neuro- Arthropathy, Tabetic Arthropathy,
Arthritis in connection with spinal lesions). — ^Two diseases of the spinal cord are
sometimes, though comparatively rarely, attended with chronic mischief in the joints
— viz., Tabes Dorsalis and Syringomyelia, In both it may occur in an early stage
of the disease, when nervous symptoms are few or absent, and in both extensive
disintegration of the joint may take place, without pain, heat, or redness, and without
giving rise to much inconvenience. In tctbes dorsalis the associated joint lesion is
known as tabetic arthropathy, or Charoot'i joint diteaie, because it was he who first
identified the connection. This lesion may occiir without the patient suffering any
pain, and but little inconvenience, although the bone ends may be enlarged, and it
may go on to extensive disorganisation with increased mobility and new bony forma-
tions before the patient seeks a doctor's advice. A case of tabes dorsalis is narrated
by Prof. J. M. Charcot of a soldier, in whom actual dislocation of both hips was found
to have occurred without the patient being aware of any mischief in the joints.
Indeed, it had happened while he was on the march. In all such cases the pupils
and knee jerks should be examined. The knee is the favourite situation, and therefore
it is sometimes difficult to test the tendon reflexes.

Syringomydia is characterised by muscular atrophy and ansesthcsia at the ends
of the extremities. Any joint may be involved ; in two cases I have seen very ex-
tensive disease affected the joints of the upper extremities.

In Raynaud's Disease a subacute or clut>nic synovitis sometimes occurs which is
possibly of vaso-motor origin.

GROUP III. MUSCULAR DISEASES,

We are here concerned with lesions situated in the muscular substance
as evidenced by pain in the muscle (myalgia) and tenderness, accom-
panied, perhaps, by some swelling. The causes of pain in the limbs were
discussed in § 422. The causes of muscular weakness will be dealt with
in the chapter on nervous diseases.

I. Muscular rheumatism or gout.
II. Tumours.

III. Trichinosis.

IV. Idiopathic myositis.

§ 448. I. Mosonlar Rheumatism is certainly the most frequent c^use
of muscular pain and tenderness in this country. It is difficult, if not
impossible, to separate gouty from rheumatic muscular inflammation.
Symptoms, — (1) The pain usually comes on quite suddenly ; so suddenh

1 " Lectures and Essays of Sir James Paget." edited by Mr. Howard Marsh, London*

1879.

2 " Lectures on the Pathology of Hysteria," the Lancet, January 20. 1904, and
♦* Lectures on Hysteria," Glaisher, London, 1909.

f 44S ] GROUP III,— MUSCULAR DISEASES 629

indeed, in the case of lumbago, that it is often mistaken for a sprain or
rupture of the muscular fibre. It is greatly aggravated by movement
and relieved by rest. In the more acute cases it is attended by localised
tenderness. (2) Little or no swelling can be detected in the affected
muscles, a point of distinction from trichinosis and new growths. (3) It
is usually accompanied by a furred tongue and disordered digestion, with
constipation and a copious deposit of lithates in the urine. There may
be slight pyrexia.

The commonest variety of muscular rheumatism is lumbago, where
the pain is situated in the muscles and fascia of the small of the back.
It is usually of very sudden onset, often when in the act of stooping.
Rheumatic torticollis is a rheumatic affection of the sterno-mastoid,
and is met with chiefly in children. Intercostal rheumatism is a similar
affection of the intercostal muscles. Lumbago has to be diagnosed from
other causes of lumbar pain (§§ 269 and 340). In aneurysm of the dorsal
aorta the pain is more continuous, not so easily relieved by muscular rest.
In myelitis and meningitis there are other symptoms referable to the
nerve trunks, sensory, or motor. Muscular rheumatism, though not
lethal, is very painful and incapacitating, and is very prone to recur.

Etiology. — Muscular rheumatism generally arises in gouty and rheu-
matic subjects who present other evidences of lithsemia (§ 249). It is
usually determined either (i.) by a chill, especially after prolonged exertion
accompanied by profuse perspiration, or (ii.) a muscular strain. It
comes on especially in cold and damp weather. Cold or damp alone do
not seem able to produce it ; it is when the two occur together, and
especially when combined with errors of diet, that the disease is chiefly
produced. Sugar, rich foods, and sweet heavy wines are most potent
for evil. Professor Ralph Stockman^ has found fibrous nodules in the
muscles, tendons, fascia, and nerves in chronic rheumatism, which swell
and become more painful in cold, damp weather.

Treatment, — The treatment must be directed on the lines laid down
for gout and rheumatism in other parts, and consists mainly of free pur-
gation with calomel and salines, of alkalies, sodium salicylate, or guaiacum
(F. 96) ; quinine and iodide of potassium are useful in protracted cases.
Rest is necessary for the pain ; and even morphia may be required.
Locally, counter-irritants are best. Lint soaked in a mixture of equal
parts of liniment of belladonna and chloroform should be kept over the
muscles (or in hospitals, liniment of turpentine does equally well, and is
very much cheaper) ; it should not be covered up with oil silk, or it will
blister. Dry heat is very efficacious. The galvanic current allays the
pain and promotes recovery in some cases. Ionic medication with sodium
salicylate is sometimes efficacious. Warm underclothing and a flannel
belt may prevent recurrence. The diet must be simple red meat,
and sugar and alcohol should be avoided (see also § 437). Sometimes
an attack may be aborted by massage and a Turkish bath. Dr. Stockman

1 Brit. Med. Joum., February, 1004. p. 477.

630 THE EXTREMITIES [ { M4

(loc. cU.) advises that the nodules be massaged perseveringly, in Epite of
the pain caused, for six oi eight weeks ; and that this should be followed
by eieroisea to stretch the muscles and aponeuroses.

II. Tumonn in tlie Bubstance of the muiicleB may give rise to pain and t«ndemeas.
tisually oesooiated with swelling. The pain and tondernees are in tliis cose strictly
locali&ed, at any rate at Grat. to the seat of the diBease. and there is a thickening or
tunoar discoverable on careful palpation. In some oases — e-g-, ayphilitic and maUg-
naat growths, the lymphatie glands in the neighbourhood ore enlarged. The chief
tumours afiectii^ muscles are (a) innocent — sj^bilitio gumma ; absccea, which ma;
arise from a gumma, or bo of in6ammator; origin ; innocent nccplaama such as fibroma,
lipoma, angioma, and hydatid or cyBticorcua cysts. (j>) Malignant growths, sarcoma,
and carcinoma (by eitension). First determine whether the aweliing ia inflammatory
or noD-inflammatoiy, malignant (and rapidly growing) or non- malignant, by an in-
vestigation of the swelling, the glands, the history, and the concurrent symptoms.
The diagnosis and treatment is mainly surgical.

{ 444. III. Trichinorii is a disease due to the presence of a nematode worm (the
triohina spiralis), in the inteatinal oanal, and the dissemination of the embryos in
the blood and the muscular system, consequent on the ingestion of " measly " meat
(usually pork) insufficiently cooked. It ia rarely met with now. The female advU
or inb^stinal worm measuraa about
Jl inch, the male slightly lees. In
ftecal exaiDinations Cor the parasite
it should be remembered that the
characteristic feature is the " cell
body " at the anterior part of the
int«atine of the parasite. The Zorrts
(Fig. 124) or musole trichiun are
found in infected muscle, where they
are visible by the aid of a ) or
1 inch lens. Each consists of an
ovoid capsule (translucent, or in-
filtrated with lime salts, according to
the length of time it has existed) con-
taining two or more embryos coiled
up within it. The tmbrytM are 0'6
to 1 mm. long, with pointed head
and rounded tail. The presence of these larvie give to pork or other infected meat
a oharaeteriatio " measly " appearance visible to the naked eye. Trichina is chiefly
conveyed to man by " measly " pork, ineufGciently cooked ; the capsules are digested.
and the embryo set free in the intestinal canal. During the ensuing week the embryos
grow and attain sexual maturity ; each female being capable of producing several
hundred embryos. After fecundation the female worm penetrates the walls of the
intestinal canal ; hundreds of embryos reach the lymph spaces and blood, and are
carried ohiclly to the muscles, where after two or three weeks they become encysted.
They have been found to be alive and capable of developing tan or more years after
their entrance.

Sym'ptoma, — The disease runs a course of several wcoks, and consists of three well-
marked stages. The first stage, before the lorvn begin to migrate, lasts nsnaUy
about a week or ten days, during which the symptoms are those of gaetro-intestinal
disturbance attended by al>dominal pain, with more or less diarrhcEa and vomiting.
The second atago, which iaets from two to three weoka, is coincident with the active
migration of the embryos. This gives rise to acute universal muscular pain, tenderness.
and sometimes swelling. The wandering of the embryos in the muscles produces
shortening and rigidity ; the biccpa soem sppaially apt to bo affected, lesulting in
a typical flexion. In severe casoa, movement of the affected muscles — e.g., turning
the oyoball, chewing, swallowing, etc., aggravates the pain. Pyrexia, of a remitting
or intermit ting type, ia present, with profuse parspirat ion. inability to sleep, and possibly
delirium. In some cases there is extreme dyspnou from implication of the diaphragm.

§ 446 ] TRlOHINOSia—M rOSITIS 631

There may be general oadema. starting in the faoe, and later on emaciation. In slight
cases the muscular and other symptoms may be so insignificant as to be altogether
overlooked. In the third stage the acute symptoms gradually subside, great muscular
weakness ensues, and recovery is slow. This stage is apt to be interrupted by various
complioations, especially pneumonia, pleurisy, or persistent and intractable diarrhosa.

In slighter cases the Diagnosis from muscular rheumatism or other diseases in this
group may present difficulty, though the widespread muscular tenderness of trichinosis,
the history of gastro-intestinal symptoms, and the epidemic occurrence in a whole
family should aid us. The stools after a large dose of calomel may be searched for
the adult worm, and it has been suggested to remove a small portion of muscle by
means of a harpoon for microscopic examination. Some cases are mistaken for enteric
fever, and vice versa. In trichinosis there is marked leucooytosis — reaching 30,000
per cmm. or more — due mainly to an enormous increase in the eosinophil cells which
may amount to 50 per cent, of all the leucocytes as compared with the normal 2 to
3 per cent., and the embryos may be found in the blood.

Prognosis, — The disease not infrequently ends fatally between the third and sixth
week ; the mortality var3ring from 2 to 30 per cent. The intensity and duration of
the symptoms is a fair measure of the prospect of recovery. Death may occur from
(i.) diarrhosa, (ii.) asphyxia (from involvement of the respiratory muscles) ; (iii.) from
exhaustion ; or (iv.) from hsomoptysis or pneumonia. In any case health may not be
restored for several months.

Etiology. — The disease is due entirely to the ingestion of " measly pork *' or other
meat, and occurs in an epidemic form in families and towns. It is much more frequent
in Northern Germany, where underdone pork or ham is a popular food, than in
England and France. Thorough cooking will destroy the parasite, but in large joints
the cooking temperature may not be sufficiently high to destroy the parasite in the
interior. All meat, particularly sausages and pork, should be thoroughly well cooked.
It is said that 170° F. will destroy the larv» but that 107° F. will do if maintained
long enough. This temperature must permeate to the interior of the meat.

TrecUment. — If the patient is seen within two or three hours after the ingestion
of infected meat an emetic should be given. If the disease is discovered within
twenty-four or thirty hours the gastro-intestinal tract must be thoroughly cleared
out. Glycerine in large doses has been recommended in the first stage for its hygro-
scopic properties to destroy the nematode, fllix mas, kamala, santonin, thymol,
and turpentine are also recommended. If, however, the second stage is reached,
and the embryos are migrating, the treatment must be symptomatic, because nothing
will destroy them. For the pain and tenderness, opium and other anodynes may be
required.

f 445. IV. Myoiitii, or inflammation and swelling of the voluntary muscles* is
a rare condition ; only a few oases have been placed on record. Three forms are
recognised by authors : (a) A localised form, in which pain, tenderness, swelling,
and impaired movement are localised to one muscle or a group of muscles ; (6) an
acute generalised form in which these symptoms, accompanied perhaps by osdema
and redness of the skin, are more widespread ; (c) a progressive generalised form of
myositis in which the disease runs a prolonged course spreading from muscle to
muscle. An example of this variety is reported by Dr. J. K. Fowler.^ The disorder
began in the left thigh, and in about two years became general. It was characterised
by painful knotty swellings, and followed by general wasting of the muscles. In
myositis ossificans the process goes on to the formation of bone.

The Diagnosis of myositis appears to offer some difficulty, especially from trichi-
nosis. A microscopic examination by means of a harpoon would afford aid in the
aouter cases, and the prolonged progressive course of myositis aids the diagnosis of
chronic cases.

The Causes of idiopathic myositis are very obscure. It seems probable that Syphilis
may have been in operation in some cases. Glanders and Actinomycosis also affect
the muscles. The acute localised form is generally the result of injury, or spread from
surrounding structures. Some think that the generalised varieties are essentially

1 Clin. Soc. Trans., April 23, 1897.

632 THE EXTREMITIES [ § 446

of nervous origin. Dr. F. Parkes Weber, who has kindly supplied me with several
referenoes.^ regards suoh oases as neuro-dermatomyositis.

In regard to Treatment^ iodides may be tried. In Dr. Fowler's case the only treat-
ment which proved of service consisted of warm baths, which relieved the pain and
stifEness.

GROUP IV. BONE DISEASES.

It would be out of place to deal at any length with diseases of the
bones, which belong in a special manner to the surgeon. Nevertheless,
these diseases frequently come under the notice ot the physician, especially
in their early stages. Pain and deep-seated tenderness are often their
chief and sometimes their only symptom. Pyrexia and constitutional
derangement may be present. Deep-seated swelling and deformity may
appear later, and, if the bone is superficial, oedema and redness of the
skin. The majority of bone diseases are chronic.

Acute Bone Diseases.

I. Acute osteomyelitis.

II. Acute periostitis.
III. Acute epiphysitb.

Chronic Bone Diseases and Deformities.

I. Rickets.

II. Chronic periostitis, osteitis, caries, and necrosis.

III. Tumours of bone.

IV. Acromegaly.

V. Achondroplasia.
VI. Pulmonary osteo-arthropathy.
VII. Osteitis deformans.
VIII. Mollities ossium.
IX. Leontiasis ossea.
X. Multiple myeloma.

§ 446. Acute Infective Ofteomyelitii (Synonyms : Acute Periostitis. Acute Necrosis).
— This disease, which used to be known as acute necrosis, and later as acute peri-
ostitis, is an acute inflammation affecting one or more of tho bones, accompanied
by severe constitutional disturbance — on which account the case comes under the
notice of a physician. This is the only really acute bone disease, though acute
symptoms very closely resembling those of osteomyelitis may arise in association
with a LOCALISED PERIOSTITIS such as results (especially in children) from an
injury.

The Symptoms of acute osteomyelitis are (1 ) pain of a very severe character coming
on suddenly, and attended by extreme tenderness, starting usually at the articular
end of the bone — very often the tibia — attended in the course of a day or two by
swelling of the limb, at first pale, and afterwards red, as the inflammation makes its
way towards the surface. (2) The constitutional symptoms come on suddenly, and
are very marked. The temperature is high, and there are rigors and great prostra-
tion. The Diagnosis from acute rheumatism, which it may at first resemble, because

1 (1) Max. Levy-Dom, " Polymyositis and Neuritis," BeH. Klin. Woch., Septem-
ber 2, 1896 ; (2) E. Wagener, " Bin FaU von Acuta Polymyositis," DeuL Arch./. Klin.
Med., 1887, p. 241 ; (3) Unverricht, " Polymyositis Acuta Progressiva," ZeiLf. Klin.
Med., vol. xii., p. 633 ; (4) Unverricht, " Dermatomyositis," DeuL Med. Woch.. 1891.
p. 41 ; (5) Hepp, " Ueber Pseudotrichinose," BeH. Klin. Woch., 1887. p. 297, etc. ;
(6) Senator, in DetU. Med. Woch., 1893, p. 933 ; (7) Senator, in ZeiL f. Klin. Med.,
1889. XV., p. 61.

§447]

QROVP IV,— BONE DISEASES

633

of the pain starting near a joint, is made by the fact that in rheumatism the pain and
swelling are confined to the joint, by the early involvement of other joints and by
signs of cardiac complications. Acute epiphysitis is mentioned below. The Prognosis
is always very grave. If the patient survive the initial constitutional disturbance
the malady leads to abscess, necrosis and tardy convalescence. The most frequent
complications are pyemia and the extension of the inflammation to a joint. Etiology.
—Acute osteomyelitis is more frequent in children under the age of puberty. It
may occur as a sequel to the continued fevers. Treatment, — A surgeon should be
called in at once to consider the advisabibty of free incision, drainage, and other
surgical measures.

Acnte Localised Periottitii may arise from traumatism, and if not infected it soon
subsides. If infected either from a wound or from the blood, suppuration and necrosis
take place, and the condition becomes chronic (§ 448). which is more common than
acute periostitis.

Epiphyiitif is inflammation beginning in the growing line, which in early life
separates the epiphysis from the shaft of the long bone. The acute form is met with
in very early infancy. Suppuration soon sets in, and spreads to the joint, forming
abscesses. It may rosomble acute osteomyelitis, but the profound constitutional
disturbance is lacking. It is distinguished from acute rheumatism by the age of
the patient, and by the development of abscess. In the chronic form the process is
much slower, and is of interest chiefly in relation to the diagnosis of rickets, from
which it differs in being localised to one joint. As regards causation the acute form
is generally due to an injury and sepsis ; the chronic form is generally associated with
syphilis or tubercle.

Table XXVIII. — Chronic Bone Diseases and Deformities.

•

Rickets.

Oecurrenee.
Very common.

Age Period mott
Affected.

Numbw of Bones
Affected.

Many bones
symmetrically.

Infancy (six
months to two years).

Early life.

Ch. periostitis,

osteitis, caries, and

necrosis.

Common.

One bone ; may be
several in syphilis.

Tumours.

Relatively
uncommon.

All ages.

Starts in one bone.

Acromegaly.

Rare.
Very rare.

Twenty-five to forty.

Congenital.

After middle age.

After middle age
(men).

Twenty-flve to thirty-
five (women).

After middle age.

Extremities and face.

Whole skeleton.

Arms chiefly.

Long bones.

Achondroplasia.

Pulmonary
osteo-arthropathy.

Rare.

Osteitis deformans.
MoUities ossium.
Leontiasis ossea.

Very rare.

Whole skeleton.

Very rare.

Facial and cranial
bones.

§ 447. I. Rickets (Synonym: Rachitis) is a constitutional disorder of
childhood attended with epiphyseal enlargements and other deformities
of the skeleton. It was described by Glisson in 1675.

The SymfUyms for which we are consulted, coming on between the
sixth and twelfth month, are delayed dentition and walking, or the child

«84 THE EXTREMITIES [§447

cannot '' sit up " ; gastro-intestinal disorders ; bronchitis ; sweating
about the head ; or a generalised tenderness and restlessness. In the
limbs the disease is typically shown by the enlarged epiphyses, affecting
most, if not all, of the long bones. The rib- ends are the first to show
the enlargements at their junctions with the costal cartilages and thus
produce an appearance of " beading " — the " rickety rosary." The long
bones often curve, a condition most commonly seen in the tihm and fibulsB.
The convexity of the curve is outwards, and greenstick fractures may be
produced by slight injuries. The spine has a general backward curvature
when the child sits up, due to laxity of the ligaments ; scoliosis may ensue
later. The head is square-shaped, both the frontal and parietal eminences
are prominent. The anterior fontanelle may remain open after the
second year (normally it should close between fifteen months and two
years of age). There may be craniotabes (thinning of the skull bones)
especially of the occipital region. The body may be emaciated or plump
and flabby. The chest is deformed, due to sinking in at the costochondral
junctions, so that the sternum and cartilages stand out prominently in
front, and are united to the ribs along a deep lateral groove (see Fig. 35,
§ 74). Another groove (Harrison's sulcus) iims transversely across the chest,
just above the lower costal margin. The liver and spleen are both enlarged
in advanced cases ; the costal margin is everted, and the belly is prominent.
The joints are loose, permitting of hypermobility. There is always gastro-
intestinal trouble, and bronchitis is frequent. There is instability of the
nervous system, sometimes evidenced by convulsions, tetany, or laryn-
gismus stridulus ; nodding spasm is more rarely present.

Diagnosis. — The disease may have to be diagnosed from hereditary
Sjrphilis, in which there may be enlargement of the epiphyses, but this
occurs usually only in one bone, and is accompanied by other undoubted
signs of syphilis. It may also need to be distinguished from the other
diseases of this group which affect children. Infantile paralysis soon
exhibits muscular wasting. Achondroplasia (§ 449) is a rare condition
which has only recently been distinguished from rickets. In infantile
scurvy (§ 413) the swellings affect the shaft rather than the epiphysis,
and are painful. The diagnosis of rickets, hereditary syphilis, and hydro-
cephalus is given in the form of a table on the next page. It is chiefly
in regard to the form of the head that the diagnosis between hydrocephalus
and rickets presents any difficulty.

Prognosis, — The disease when taken in hand before osseous changes
are marked is readilv amenable to treatment. If untreated it leads to
deformity. If death occurs it is due to some of the common complica-
tions, notably pneumonia, bronchitis, or gastro-intestinal disorder, and
wasting, or convulsions. Spinal, pelvic, and other deformities or hydro-
cephalus may result, and the growth is stunted. Genu- valgum (knock-
knee), genu-varum (bow-leg), and flat-foot often occur.

Etiology, — Rickets rarely appears earlier than six months or later than
the second year. Both sexes are equally affected. The disease is more

§447]

RICKETS

636

frequent in cities, and impure air may play a part in its production, but
it may also be found in the country and among the wealthy. Too pro-
longed lactation, suckling during pregnancy, and too rapid pregnancies
in the mother predispose to rickets in the offspring. However, it is now
generally admitted that the essential cause of rickets is a defect in the diet.
The diets on which rickets is produced all show, according to Dr. Cheadle,
a deficiency in two constituents — animal fats and proteids. A deficient
assimilation of lime salts also appears to aid. Too early or excessive
administration of carbohydrates and particularly the proprietary infant
foods rich in starches is in actual practice a frequent cause.

Table XXIX. — Differential Diagnosis.

I. History.

II. Age of patient.

RiekeU.

Gastro-intettinal irri-
tation, sweating
abont head. Im-
proper feeding.

Commences in in-
fancy and begins to
show itself during
the first or second
year.

III. Shape of head. i Of ten compressed Irregular prominence

Hereditaty SyphUit.

Snaffles and rash.
Miscarriages in
mother.

Hydroeephalut.

Symptoms first ap-
pear third week to
the third month.

Congenital, or may be
acquired after some
meningeal inflam-
mation, or due to
tumour pressing on
veins.

Congenital
quired.

or ac-

IV. Fontanelles.

antero - posteriorly.
I Frontal eminences
' marked.

Close late.

V. Other peculiari- Epiphyseal enlarge-
ties. ments, delayed den-

tition, etc.

on each frontal and
parietal bone. Skull
has been called nati-
form. Depressed
bridge of nose.

Bulges in all direc-
tions. General ten-
dency to assume a
globular form.

Appear to be de- < Bulging, separation of
pressed in the hoi- ' the bones at the
low between the sutures,
four prominences.

Pegged and notched Stunted growth, men-
teeth. Scars about tal deficiency,
mouth, palate, etc.

The TrecUment must be mainly dietetic (compare children's dietary,
§ 212a). Carbohydrates must be reduced, and raw-meat juice, milk-
casein, or other proteid food-stuffs, and good milk and cream added.
Cod-liver oil is the best drug to give, either alone or combined with lime
preparations and with iron. Phosphorus j^ grain three times a day
in oil is recommended. One of the best remedies for unhealthy stools
is F. 64. The child must not be allowed to walk lest the bones yield
and produce permanent curvatures. Fresh air and sunlight are neces-
sary adjuncts to dietetic and tonic treatment. Should the bones have
already some degree of curvature, further yielding is prevented by placing
the legs in restraining splints, which if carried beyond the feet will efficiently
prevent any attempt at walking or standing when the mother's back is
turned. Rolled up newspapers form a useful splint.

636 THE EXTREMITIES [ §§ 448, 449

S 448. n. Under Chronic Of teitis and Perioftitis are included a number of tuber-
culous, syphilitic, and other conditions leading to caries, necYosis, and other anatomical
changes in the bone. Osteitis and periostitis may be dealt with together, for although
the disease may start in the bone or the periosteum it soon spreads to the other.

The Symptoms of osteitis and periostitis may have oome on with acute pain, red-
ness, and swelling ; but more frequently they come on insidiously with hardening,
thickening, or enlargement of the bone. These symptoms may be followed by soften-
ing (caries) or death of a portion of the bone (necrosis) with signs of abscess formation.

Causes and their differentiation : (1) Traumatism alone, without sepsis or tozsmia
of some kind, is a rare cause of chronic periostitis or osteitis. Traumatism is recog-
nised by its history, and by the fact that only one booe is affected. (2) The favourite
seat of tubercle is the epiphysis, whore it induces a chronic epiph3^itis, especially
in the neighbourhood of the hip or knee. Sometimes it gives rise to osteitis, and
when this occurs in the fingers it results in a characteristic thickening of the phalanges
known as tuberculous dactylitis. In any position it may go on to caries or necrosis.
Tuberculous affection of the bones is recognised by (i.) the youthful age of the patient ;
(ii.) a tuberculous history ; (iii.) by the characteristic intermitting pyrexia ; (iv.) signs
of tubercle in the lungs and elsewhere ; (v.) by the chronicity of the process ; and
(vi.) the frequent limitation to one bone. (3) Syphilitic affections of the bones
are very common both in the acquired and the hereditary disease, (a) Acquired
syphilis may take the form of a chronic diffuse or localised periostitis (nodes), or,
on the other hand, a diffuse or a gumnrntous (localised) osteitis. It is recognised
by (i.) the characteristic fiying pains in the limbs ; (ii.) the nocturnal pains in the
bones, which are such a frequent manifestation of syphilis ; and (iii.) other evidences
of syphilis. (6) Hereditary syphilis may give rise in childhood and early life to the same
lesions as the acquired disease. In infancy (in addition to the foregoing) chronic
suppurative osteochondritis (chronic epiphysitis) is apt to arise and to be mistaken
for rickets. In this condition one or several bones may be affected, but it never
presents the same symmetry as rickets. The deformities resulting from hereditary
lesions (f 404) and the physiognomy are very often characteristic — ^the bosses on the
frontal and parietal bones (Parrot's nodes), the depressed bridge of the nose, soars
about the angle of the mouth, Hutchinson's teeth (Fig. 3, § 11), and perhaps keratitis.
(4) Rheumatism and gout may give rise to chronic periosteal thickening, or periosteal
nodes.

For the adequate Treatment of most of these different conditions, rest and surgical
aid are necessary. The treatment of the tuberculosis, syphilis, rheumatism, and
gout have already been dealt with.

m. Tumours of Bones may commence with pain, tenderness, and swelling like
chronic periostitis. The chief innocent tumours are exostoses, which may occur
on almost any bone, and BNOHONDBOBfATA, which are commonest on the metacarpals
aud phalanges. Both are usually multiple. The malignant tumours are either
SABGOMA (especially myeloid sarcoma) or carcinoma. In both the swelling of the
bone is more rapid, and reaches a greater degree than in any of the other causes of
swelling above mentioned, and as a rule they are limited, at any rate at first, to a
single bone. Spontaneous fractures may occur.

§ 449. Nine rare forms of chronic bone disease must be mentioned.

IV. Acromegaly is a rare disease first described by Dr. Pierre Marie, leading to
enlargement of the skeleton. The patients generally apply for treatment for some
other malady, though sometimes they apply on account of the awkwardness of their
movements, and sometimes they complain of obscure pains in the limbs. The aspect
is very characteristic. The bones and other tissues of the hands and feet become
markedly elongated and hypertrophied, though the growth is so gradual as to escape
the patient's notice. The cranium is increased, but not so much in proportion as the
face, which is egg-shaped, the lower jaw representing the large end of the egg. The
lower jaw especially is enlarged, and may project beyond the upper jaw. The nasal
bones are also enlarged, whilst the thickening of the soft parts causes hypertrophy
of the ears, eyelids, nostrils, and tongue. Later in the disease there may be a sindlar
enlargement of the bones of the limbs and the thorax, and kyphosis of the spine.
Sometimes there is temporal hemianopsia, with gradual optic atrophy.

IMS] ACROMEGALY— ACHONDROPLASIA 637

Diagitont. — Myxiedcma reiemblcB acromegaly, but it is known by its roDiid or
" mooD-aluipeif " f&oe, the drj shin, and the absence of all bony enlargement or
musDiilsr wBakneaa. Pnlmonary oBteo-orthropatby (eeo below).

Aoram^aly oocara rather more frequently in women, generally beginning abont
the twenty-fifth year. Changes in the pituitary body, either hypertrophy or tumour,
h>re been found in all the fatal caees. It has been suggested that gigantism and
acromegaly are one and the same disease, and that both arc due to disordered function
of the pituitary gland, and it \s worth noting that in the skulls of certain giants tlie
mA\t, turcica has bern found to be considerably enlargi'd. In some esses there liave
also been changes in the thymus or the thyroid glands, and mediastinal dulneei has
been mode out during life in the position of an enlarged thymus.

rreaimeiK.— Acromegaly nins a very prolonged courie of many years, and no
known treatment seems to aflect it. Extract of thyroid may be tried. The patient
generally dies of some intercurrent malady.

V, Achondtoplula (Synonyms : Fistal Kicketa, Chondrody atrophia FtBtalis) is a
rare condition of infancy leading to dwarfism and generalised deformity, which unUI
a few years ago was probably confused with cretinism on the one bond, or with the
deformity resulting from rickets on the other. Fig. 125 represents a case exhibited
kt the ClmicaL Society of London by Mr. W. Turner, to whom the author is indebted
(or the photographs. There is a generalised symmetrical shortening of the diaphyses
(producing characteristic shortening of the limbs) with considerable thickening of
tha epiphyses (producing enlargement of the artioniatioiu), due to hyperplasia of the

638 THE EXTREMITIES I § 449

oaitilaginoos ends of the bones. Consequently the stature is stunted, the fingers
and toes taper and are abducted from one another, the cranium is large, the face small,
and the bridge of the nose depressed. There is a characteristic waddling gait. The
disease is congenital, and dates from birth. The mental deficiency, facial aspect,
and the changes in the hair and skin characteristic of cretinism are absent, and oases
do not exhibit the oonstitutional symptoms or characteristic changes of rickets in
the skull. It is ascribed to a premature union of the diaphysis and epiphysis, so
tha^ lengthening of the large bones is arrested.

VI. Pulmonary Ofteo-arthropathy is a chronic hyperplasia sometimes associated
with chronic pulmonary disorders. There is enlargement of the hands and feet,
and of the lower ends of the long bones of tha legs and forearms, but the face and
head are not enlarged. The nails are curved over the enlarged terminal phalanges,
" filbert nails."

Vn. Otieilif Deformani (Synonym : Paget's Disease) is a somewhat rare disease
coming on after middle life, mostly in males, and consisting of a very chronic enlarge-
ment of the bones, both in diameter and in length. The histological change is a rare-
fying osteitis with enlargement of the Haversian spaces. It affects the cranium
(not the face), spine, limb, bones, and clavicle. It becomes manifest to thp patient
by the fact that he frequently has to change the size of his hat. Sometimes rheumatic
pains in the bones are complained of. The head is projected forwards, associated
with kyphosis in the dorso-cervical region, so that the attitude is characteristic.
The base of the chest is expanded, the abdomen diamond-shaped, and crossed by a
deep transverse sulcus, the hips are widened, and the legs are bowed outward and
forward.

Vni. Mollities Oniiim (Synonym : Osteomalacia) is a progressive disorder of the
bony system, due to gradual decalcification and weakening of the skeleton, which
residts in considerable deformities and contortions, owing mainly to muscular action.
It occurs in women (91 per cent., Arthur Durham) between twenty-five and thirty-
five years of age, mostly after pregnancy. The early symptoms consist of wandering
pains in the limbs and trunk, worse at night, with weakness of the limbs. In tho
course of a few months there is bending of the bones ; spontaneous fractures and
distortions may occur. The stature is diminished from the involvement of the spine.
Death usually occurs from respiratory complications owing to the fracture of the ribs.

IX. Leontiaiii Onea is the term given to a rare condition in which there are sym-
metrical hyperostoses of the facial bones and skull, which encroach upon the cranial
cavity, and so may lead to death.

X. Multiple Hjeloma (Synonyms: Kahler's disease. Myelopathic Albumosuria)
is a disease of the bony skeleton, due to a diffuse new growth of the myeloid tissues,
which erodes the ivory elements of the bones and displaces the blood-making marrow,
with resulting aniemia, and tumours on the bones. In the early stage the chief
symptom may be pain, not as a rule localised to any one position, but varying from
day to day. The patient complains of gradually increasing debility ; and the bones
may bend or fracture without apparent cause. The urine is found to contain the
Bence-Jones protein (see f 276, albumosuria), and may be milky when passed or on
standing. Sometimes the discovery of this constituent in the urine is tiie means of
diagnosing the disease in an early stage, when nothing beyond weakness and pains
are complained of. The disease has in the past been confused with Mollities Ossium.
Myelopathic albumosuria affects for the most part males over the age of thirty-five.
No treatment is known. The disease is fatal in about one to four years.

XI. Ofteogenefit Imperfecta is a condition occurring during intra-uterine life or
soon after birth, manifested clinically by multiple fractures without sufficient cause,
or sometimes by acute bending of the bones. The fractures may not heal, or heal
only with difficulty and much callous formation.

XIL Cleido-oranio-dyioftoiii is a congenital defect. There is absence of bone at
the outer third of the clavicle, with persistence of the acromio-clavicular ligament,
and deficient ossification of the cranial bones.

CHAPTER XVIII

THE SKIN

The skin is subject to the same diseases as other epithelial structures,
but the circumstance which strikes the thinking student is that, although
various skin diseases have, as it were, written their own characters on
the surface of the body in full view of the observer, we have hitherto
learned really less about the pathology of morbid processes which occur
in the integument than we have about those which take place in most of
the other parts of the body.

Another circumstance which increases the mystery surrounding skin
disease is the immense number of names adopted by dermatologists
for the same or but slightly different diseases. It has not been possible
to give all the synonyms for the various recognised tjrpes of disease in
the following pages, but a glance at the disease now usually known as
dermatitis herpetiformis will give some idea of the mysteries and diffi-
culties of this nomenclatural maze.

I am happy to say that this tendency to cut up a disease into an in-
finitude of varieties and subvarieties seems at last to be on the wane, and
that a more scientific tendency to trace several differently named varieties
to one morbid process has set in.

PART A. SYMPTOMATOLOGY,

The cardinal symptom of skin affections consists of an eruption with
or without subjective symptoms. The subjective symptoms of skin
diseases are of relatively less importance for diagnostic purposes, because
the morbid process itself is before us. There is, however, one subjective
symptom which attends a great many skin diseases — ^namely, pruritus
(itching). AnsBsthesia and other disorders of sensibility will be dealt
with among diseases of the nervous system.

§ 450. Pmritos is the Latin word for itching, and that is the sense in
which it is used here.

There are three groups of Causes of itching :

(a) Pruritus may be secondary to some visible skin disease, and in
that case the itching is localised to the neighbourhood of the eruption.
Some eruptions are invariably attended by itching, such as urticaria,
eczema and most acute conditions which progress rapidly. Other diseases

689

640 THE SKIN [ § 461

are generally unattended by it<5hing, such as syphilis, psoriasis, and most
chronic conditions which evolve their course slowly.

(6) Various local conditions may produce more or less localised itching :
(1) Discharges or secretions from nasal, buccal, or anal orifices, e.g.,
pruritus ani, pruritus scroti, pruritus pudendi. In many of these cases
there is also a certain amount of localised eczema, which is possibly also
the result of the discharge or sweat. (2) A rough garment, such as a new
flannel shirt or certain dyed articles, may produce intolerable itching in
delicate skins. (3) Various parasites give rise to pruritus. With scahies
there is also a characteristic eruption localised chiefly to the flexures
of the joints. In fhthdriasis (due to pediculi corporis) the eruption is
generalised, though most intense across the shoulders ; the fiea, the
harvest-hug, fediculus jmbis, and other parasites cause intense itching.

(c) With idiofothic or internal causes the itching is generalised, and
may or may not be accompanied by a certain amount of generalised
eruption of papules (see Prurigo, § 464). Among the causes may be
mentioned gout, certain articles of food (e.g., shell-fish, eggs, cheese,
excess or deficiency of salt), jaundice, digestive disorders, lithsemia, dia-
betes, Hodgkin's disease, kidney disease, pregnancy, nervous irritability,
constipation, and old age. The pathological condition on which all of
these depend is in the author's view^ some blood change. Pruritus,
with congestion of the nasal and intestinal mucosa, also occurs in slight
degrees of anaphylaxis. Some contend that itching may be due to
neurosis ; thus nervous persons complain of much itching long after the
causal condition has been removed. The Treatment of pruritus is given
under Prurigo.

PART B. PHYSICAL EXAMINATION.

The APPARATUS required for the investigation of skin diseases is simple,
and consists of a good lens some 3 inches in diameter, a microscope with
accessories, and the means of histological examination. A pair of flat
forceps is useful for removing scales, hair, or parasites. A flat glass slide
may be used or the skin may be stretched to ascertain if the spots dis-
appear on pressure.

Histological Examikation is of great use in many cases, and frequently enables
one to diagnose a lesion with certainty ; a small piece of the diseased skin can be
removed without causing appreciable pain if the part be first frozen by ethji chloride.
As the skin freezes pinch up the fold required with the fingers so that it retains its
«hape, then take hold of it with a forceps, and cut with curved scissors a tiny piece
(including all the layers of the skin), which can be put into alcohol, then celloidin or
paraffin for section cutting.

§ 451. The points to investigate in any given case of skin eruption
are : I. The size and appearance of the prevailing elements ; II. What
it feels like, and whether it disappears under pressure ; III. The distri-
bution and symmetry of the eruption ; IV. Subjective symptoms ; V. The
duration and evolution of the eruption ; and VI. Its etiology.

1 The Lancet, August 1, 1896, p. 300.

§452] PRINCIPAL ELEMENTARY LESIONS 641

I. The Oharacter and Size ot fhe Frevailing Elements. — The spots are
never aU quite alike, being modified by the age of each spot, the locality
afiected, and the conditions to which it has been subjected (e.^., scratching
or pressure). It is therefore of the highest importance to examine every
fart of the eruption. Patients may object to undress and the physician
may grudge the time, but these considerations should never be allowed
to weigh. The most convenient clinical classification of skin diseases is
based upon the nature of the elementary lesions, a list of which is given
below.

§ 452. The principal elementary lesions which appear on the skin are
as follows : There are three varieties of primary lesion, and three which
arise secondarily to these.

1. A macule (or macula) is a spot of congestion not elevated above the
surface of the skin ; roseola is a generalised eruption of macules ; erythema
is a larger area of congestion with fading edges. A wheal is a spot of con-
gestion accompanied by slight exudation beneath the skin ; it is also called
urtiea, and a generalised eruption of wheals is called urticaria or '* nettle-
rash," because it resembles nettle stings. When large, the wheal is
white in the centre and red around.

2. A papule (or pimple) is a small solid elevation of skin, conical, round-
topped, or flat. A lenticular papule is a large flat-topped papule. A
tubercle, or nodule, as it may be better called, to avoid confusion with the
lesion of tuberculosis, is larger than a papule, but not large enough to be
called a tumour.

3. A vesicle is a collection of serous fluid beneath the cuticle. A buUa
is a large vesicle. A pustule is a collection of purulent fluid beneath the
cuticle.

The SECONDARY lesions are :

1. A scale or squame is the exfoliation of cuticle which occurs after
a congestion or inflammation of the skin, or it may be the product of
pathological processes special to the skin, such as cornification, or hyper-
keratosis. In a sense a scale may be a primary lesion.

2. A crust or scab is dried serum or pus.

3. Fissures, ulcers, cracks, excoriations are breaches of the surface.
Cicalrices or scars may result from these when a sufficient extent or depth
of skin is involved.

Pigmentary Alterations are known as chloasma when there is a
broad streak of excessive pigment ; leucoderma, when there is an area of
skin devoid of normal pigment ; melanoderma, when there is an area of
increased pigmentation. Ephdis is a freckle. Ncbvus is a mole or birth-
mark, either pigmented, hairy, or vascular. A dilatation of the superficial
vessels of the skin is known as idangiectasis, Petechics are small spots
of haemorrhage into the skin. Ecchymoses are larger patches of extra-
vasated blood which go through the changes of colour characteristic of
a bruise. A comedo or " blackhead " is a little black plug of inspissated
sebum blocking the orifice of a sebaceous gland;*

642 THE SKIN [ § 462

The fundamental histological changes of the skin are congestion (hypersBmia) with
or without exudation, inflammation, and infiltration. If the lesion consists of
congestion, such as roseola, or urticaria, or simple inflammation without infiltration,
such as eczema, it disappears on pressure. If, on the other hand, there be definite
infiltration or neoplastic deposit, as in lupus and syphilis, or if there be htBrnorrhage
into the skin, the colour does not disappear when the skin is pressed by the finger
or a glass slide, or stretched. This is a point of much significance in the diagnosis
of sl^ diseases. The secondary consequences of inflammation in the skin are, as
elsewhere, three in number. If the inflammation does not undergo resolution, there
may be (1) suppuration leading to the formation of pustules, ulcers, etc. ; (2) ntcroais,
as in the centre of boils and carbuncles ; or (3) organisation, as in the case of the various
scars, hypertrophies, or scleroderma. In addition to the primary lesions just referred
to — congestion, inflammation, and infiltration and their consequences — which occur
in the skin as elsewhere, there are at least four processes special to the skin. 1. Hyper-
kereUosis is an increased deposit of kerato -hyaline material leading to an increased
comifioation of the surface cells of the epidermis, and a scaliness of the surface as in
pitjrriasis and psoriasis. 2. Parakeratosis is the irregular or deficient comification
which occurs, for instance, in eczema. Here the prickle cells, instead of going through
the regular process of comification by the deposit of kerato-hyaline granules in their
interior, and their gradual conversion into dry, homy, non-nuclear cells, remain moist
and succulent (though dry on their exterior), and retain their nuclei. They adha«
to one another, being moister, and are shed in masses of crusts and scales instead
of being shed singly and imperceptibly. 3. Acanthosis is a term applied to the
increased proliferation of the prickle cells by increased mitosis (karyokinesis), resulting
in an increased thickness in the epithelial layers of the cuticle. 2 and 3 are found
in aU kinds of eczema, 2 chiefly in dry eczema ; 3 is met with in moist eczema.

II. What does the eraption feel like, and does it disappear on preisiiie ?

Infiltrating lesions feel hard, and do not entirely disappear on pressure,
as is evident from the histological characters (vide supra). A faint purpuric
eruption may thus be diagnosed from an erythema.

III. The difltribation, position and symmetry of the eruption is important
for purposes of diagnosis,and it is therefore most essentia] to examine
the whole of the eruption. Many diseases may be recognised by the
position in which the elements predominate, and Figs. 126 and 127 will
aid the student to remember the parts most frequently affected by certain
eruptions. Some diseases are always more or less generalised — e.g.,
urticaria and the exanthemata, and this generaUsed distribution usuaUy
indicates a toxsemic or idiopathic cause. Others, while sometimes affect-
ing the whole body, have a preference for certain parts — c.^., psoriasis
for the knees and elbows, seborrhoeic dermatitis for the head and shoulders.
Various words are used to describe the distribution, thus, punctate when
the eruption is dotted about, discrete when the elements are separate,
confluent when they run together, gyrate or crescentic when they are
arranged in wavy lines or segments of circles, circinate or annular when
they are in circles, corymbose when grouped into clusters.

Any symmetry of arrangement on the two sides of the body should
be carefully observed, though its significance must not be overrat'ed.
It may indicate that some constitutional or blood change is in operation
as in the earlier eruptions of syphilis. Symmetry may also indicate that
some nervous or neuro- vascular cause is in operation, as in certain erythe-
matous eruptions. But perhaps the commonest cause of synmietry is
the fact that both of the parts involved are exposed to the same extraneous

1452]

PHYSICAL EXAMINATION

643

FRONT

BACK

Figs. 126 and 127. — DUQRAM showing the parts most frequently affeeted by certain araptions.

H44

THE SKIN

[§468

conditions, as in eczema of both hands due to washing in strong solutions
of soda.

IV. The presenoe ol SnbjeotiTe Symptoms must be inquired into, such as itching,
burning, smarting, etc. Syphilitic eruptions do not usually itch, a feature which
helps to distinguish them £rom the corresponding non-syphilitic rash. The majority
of skin diseases are unattended by constitutional symptoms, if we except tuberculous
and syphilitic eruptions, and the eruptive fevers.

v. The Duration ol the Eruption and the history of its Evolntion must be investi-
gated. The rate at which a disease has developed is a most important aid to diag-
nosis. For instance, lupus vulgaris will not produce so extensive a lesion in the
course of years as a facial syphilide which resembles it will produce in the course
of weeks or months. It must be remembered also that during its progress a skin
disease may alter its appearance considerably ; a lesion which starts as a papule may
become a vesicle and then a pustule, as in small-pox.

VI. The Etiology must also be inquired into. First as regards PRBDiSPOsnTG causes :
1. The €ige of the patient. Lupus vulgaris nearly always starts in early life, but
lupus erythematosus rarely starts imtil middle life. 2. Sex does not aid us much in
diagnosis. 3. Heredity is not a potent factor in skin disease, though ichthyosis,
psoriasis, cancer, and albinism have been traced in families. 4. The occupation of
a patient may result in certain skin diseases by a want of cleanliness, or may cause
various forms of eczema of the hands (grocer's itch, baker's itch, etc.).

Among the exchtno causes — 1. Traumatic conditions frequently produce a lesion
which is indistinguishable from eczema, and friction and scratching may modify the
characters of an eruption very considerably. 2. Parasites produce eruptions which
have special characters. 3. Vegetable organisms, fungi, on the surface of the body
cause ringworm, favus, and other diseases. 4. Bacteria introduced into the body are
the cause of the exanthemata. 5. Oout and other toxemic conditions are the causes
of some eruptions — e.gr., urticaria, erythema, and prurigo. 6. Many drugs are attended
by charaoteristio eruptions (§ 457). 7. Diseases of the internal organs may produce
eruptions, especially digestive disturbances (urticaria), disease of the peripheral nerves
and their ganglia (herpes and glossy skin, and other trophic changes), acute and
chronic Bright*s disease, diseases of the liver, and other abdominal diseases.

PART 0. DIAGNOSIS, PROGNOSIS, AND TREATMENT OF SKIN

DISEASES.

§ 458. Bontine Procedore and Classification. — ^The leading symptom is
generally before our eyes. The history, duration, and mode op evolu-
tion can be inquired into while the patient undresses. Then we proceed
to the PHYSICAL examination as described in Part B.

If the eruption is quite dry, and consists of wheals, macules or erythema.

papules or scales, turn first to . . . . . . . . • • § ^^

If the eruption b moist, or consists of serous exudation, vesicles, or crusts.

turn first to • • § 478

If the eruption consists of pustules, turn first to . . • • f ^84

If it is multiform • • S 489

If it is nodular . . M W

If there is ulceration . . . . • • § 492

If there are warts or excrescences . . . . • • § 493

If there are scars or atrophies . . • • S 494

If there are vascular or pigmentary alterations • • § 495

If there is disorder of the sweat • • § 497

If the hair or scalp is affected . . • • § 498

§ 464 ] URTICARIA 645

GROUP I. ERUPTIONS USUALLY DRY (Wheals, Macules or Erythema.

Papules, and Scaly Eruptions),

a. Wheals;

§ 464. Urticaria ('^ nettle-rash ") is a generab'sed eruption which con-
sists of wheak, of more or less evanescent character, rareiy lasting more
than a few hours. The rapid onset and disappearance of the individual
lesions is very characteristic. Patients come complaining of the history
of such an eruption accompanied by intolerable itching ; and sometimes
although there are no wheals visible, these can readily be produced by
drawing a point across the sldn (dermatographia or urticaria factitia).
This latter condition may very frequently be found in association with
the exanthems and erythemas. It is also present in states of cerebral
congestion (meningitis) and constitutes the tache cdr^brale of Trousseau.

Etiology, — Urticaria may be due to external or internal causes. (1) The
bite of some insects, the stings of nettles or jelly fish. Cases are recorded
in which a bath is followed by urticaria. (2) Nervous causes are rare,
but some persons develop urticaria on meeting a stranger or before ad-
dressing a public gathering. (3) The commonest cause is the ingestion
of shell-fish, tinned food, acid fruits, or other articles of diet for which
the patient has an idiosyncrasy. (4) Gastro-intestinal derangement,
worms, or other cause of toxaemia. (5) After serum injections. (6) After
enemata. (7) Drugs {§ 457).

Varieties. — (1) There is an acute and chronic form of the affection ; the
first named consists of a transient attack lasting a few hours or days ; in
the chronic or more properly the recurrent form (urticaria perstans) there
are constantly recurring attacks. (2) Urticaria papulosa (§ 464), and
(3) Urticaria pigmentosa (§ 495). (4) In giant urticaria or Quincke's disease
the eruption is more persistent and consists of circular white oedematous
spots or swellings in the skin. (5) Angio-neurotic oedema consists of still
larger swellings affecting the loose subcutaneous tissue. (6) Urticaria
bullosa is a rare variety with vesicles or bullae, met with chiefly in children.
(7) The form which sometimes appears after serum injections is associated
with a group of sjrmptoms to which the name ^' Semm Disease " has been
given. It indicates a hypersensitiveness which has been termed anaphy-
laxis (§ 388). The symptoms are usually slight after a first injection,
and appear after an incubation period of three to ten days. If the injec-
tion be repeated after the incubation period of the first is over, the symp-
toms may be pronounced, with urticaria, fever, joint and glandidar
swellings, and oedema ; in rare cases collapse and even death occur.

Prognosis and Treatment, — The disease as usually met with subsides in
a few days to a week, and a brisk saline purge is all that is necessary.
Relapsing cases are, however, difficult to cope with, and in these strict
attention to the diet and the digestive organs is called for. The remarks
under Erythema Multiforme concerning the coagulability of the blood
and the treatment by calcium chloride apply in my experience equally

646 THE SKIN [ K 456. 466

here. After any digestive defects have been corrected, it is wonderful
how efficacious 20 grain doses of calcium chloride thrice daily are in some
cases, thoujgh in others the eruption reappears on ceasing the drug.

b, Erwptions which usually consist of Macules or Erythema,

Oeneralised, Localised,

I. Exanthemata. I. [Rosaoea.

II. Roseola (siinplex and syphilitica). II. jLupus er3rthemato8us.

III. Erythema scarlatinoides. III. 'Erythema nodosum.

IV. Brag eruptions. IV. jEiythematous eczema. X-ray der-
V. Erytiiema multiforme. matitis, Erythema paratrimma,

E. faciei, E. traumatioom, E.
calorioum, E. Pernio, and other
Tarieties of E. multiforme ; Macu-
lar Leprosy, and Pellagra.
The early stages of eczema and of other eruptions to be mentioned hereafter may
take the form of an erjrthema.

I. The Exanthemata or eruptive fevers are fully described in Chapter
XV., where they form Group I. of the acute specific fevers.

§ 466. II. Roieola is a term employed to designate a generalised erup-
tion consisting of patches of congestion, more or less marginated, varying
in size from a pin's head to a lentil. Two varieties are described.

Roseola Simplez may resemble measles, and, indeed, its chief importance
is in connection with the diagnosis from this dbease (^.t;.) : it gives rise
to a considerable amoimt of itching and irritation, with usually a slight
degree of constitutional and gastro-intestinal disturbance. It may occur
in childhood under the same conditions as urticaria, and is therefore pre-
disposed to by gastric disturbance. The occurrence of such an eruption
when small-pox is prevalent should make one suspect the initial eruptions
of that disease. It is one of the commonest rashes associated with vac-
cination. Drugs, such as copaiba, may cause it. TreattnerU consists in
administering an aperient, salines, and diuretics, and in correcting any
concurrent digestive disorder.

Roseola Syifthilitica is the earliest of the syphilitic skin eruptions, occur-
ring three to six weeks after infection. It appears upon the trunk, chiefly
its anterior aspect, the chest, the flexures of the limbs and the palms and
soles, as rosy or dushy red macules, disappearing on pressure, rounded,
oval or irregular in shape with fading edges, varying in size from a pea
to a shilling. A degree of pigmentation may be left behind. Sometimes
the eruption is so faint that it is overlooked. It becomes better marked
after a bath or when the skin is exposed to cold. It may last from a few
days to a few weeks. It is diagnosed by the history and other signs of
S3^hilis. Non-syphilitic roseola imdergoes rapid changes in size and
shape ; pityriasis versicolor can be scraped oS and is fawn-coloured ;
seborrhodc eczema develops greasy scales on the surface, and forms spots
of irregular size and outline.

§ 466. III. Erythema Scarlatinoides, as its name implies, consists of a widespread
rash, resembling scarlet fever, preceded and accompanied by fever and constitutional

iW] DRDQ BRVPTIONS 647

diaturbsuoo, aod foUoved by doaquamatioD. So-Dulled " aurgiaal soarlaUua " ig
pnilMbly Ideaticol with this oonditioa. The ohiaf causob are Bflptionmia, iuteatinal
disorders, enomata of soap or other subaUnoes, the iDgestion of ptomainea and other
(oiioa, certain drugs (goo below), rbeumatiam, goaoTThcea, and aewer-gaa. The
DiagnosU from Boarlet fever is diffioult onl; in severe eases. In erTthema there is less
constitutional dislurbanoe, do strawberry tongue, and there is a tendency to relapse.
9 U7. IV. Dnii Bmptioiu. — An idiosyncrasy with regard to certain drugs, whether
taben by month or applied oKlentally, is shown by some individuals, and is mani-
fested by the appearance of a rash, which disappears on the withdrawal of the drug.
Two things will be noticed in the list below ! (1) That by far the commonest eruptions
are erythema and its congeners ; and (2) that the iodides and bromides are among the

Pig. 1£8.— BHrraBMi Ikis od the hand of ■ liiijle womaa twenty-tbiee yean ol a^e.

at dru^e to produce eruptions ; they may even produce a framhcesial eruption
resembling gumma. The chief eruptions produced by the internal admin istratton of
drugs are as f oUowa :

Papulo-Puttulea ■■ Bromide and iodide of potassium (ehietly on the face), occasionally
sulphide of calcium, antimony, arsenic, and mercury.

Erythema: Antipyrin, antitoxins, copaiba, cubebs. santal, turpentine, opium,
chloral hydrate, belladonna, atropine, quinine, mercury, salicylic aoid and sodium
salicylate, iKiroeia acid ; iodoform and carbolic acid by absorption from wound dressings.
And in the author's opinion certain toxins absorbed with milk.

Tlriicaria : Quinine, copaiba, turpentine, valerian, santonin, sodium salioylate,
benEoic, saLicylio and tannic acids.

Eryiipdaloid (erythema with infiltration or oedema of the skin) : Bromide and
iodide of potaaaium, quinine, iodnform, mercury, boraoic and carbolic acids (aconit«,
oil of uade, cbryaarobin. and uarbolio acid applied externally).

648 THE SKIN [ §§ 458, 469

Herpes : Arsenic.

BuUcB : Antipyrin, arsenio, the balsams, meroury.

Purpura : Iodide of potassium, chlorate of potash, chloral hydrate, chloroform,
copaiba.

Pigmenlation : Silver nitrate, arsenic, antipyrin.

Epidermic Thickening : Arsenic and borax.

§ 468. V. Brythema Moltilorme is an affection characterised by eiy thematons efflor-
escences, varying in form and size, localised usuaUy upon the backs of the hands and
forearms, dorsum of feet and legs, and sometimes on the face, neck, and the trunk,
and accompanied usually by lassitude and ill-health. The lesions vary in size from
a lentil to the palm of the hand. They belong to the congestive form of eruption,
being slightly raised, with fading edges. The centre is the highest part, is usually
livid, and sometimes hemorrhagic There is usually a feeling of burning or formica-
tion. Many varieties have been described, such as E, gyrata, when the blotches ^Mle
in the centre, coalesce with neighbouring ones, and form wavy or gyrate lines. E. iris
(herpes iris, herpes circinatus) is a form in which a vesicle forms in the centre, with
concentric rings of purple and white and red around it (Fig. 128). In E, buUosum
bullae form. E, nodosum is described in § 461. Erythema is known from urticaria
by its deep red coloration, by its more localised distribution, the larger size and more
permanent character of the lesions, less itching, and more marked constitutional
symptoms. Young people and males are more prone to the affection. It is com-
moner in the spring and autumn. The course of the disease varies, but each erythe-
matous patch lasts eight to ten days, and they continue to appear for two to six
weeks. Each may leave temporary brown pigmentation, and desquamation may
occur as they fade.

Treatment. — That the disease is due to some alteration of the blood is shown by
the marked effect which certain remedies have upon the condition, especially quinine,
and, as Sir A. E. Wright and the author have shown, calcium chloride.^ lliis altera-
tion appears to consist of a diminished coagulability of the blood, such as occurs
when ce^cium salts are deficient. Quinine should be given in 4 or 5 grain doses, t.i.d.
and gradually diminished, or gr. xx. calcium chloride. If given after meab these
doses do not impair the digestion. The diet and digestive system require careful
regulation.

Erythema of more or less looalised distribution.

§ 459. I. Rosacea (Synonyms : Acne Rosacea, Acne Erythematosa,
Gutta Rosacea Kupeferrosa) presents three stages : (1) Simple congestion
or erythema attacking the nose and adjacent parts of the cheek, often
worse after meals. (2) In the next stage dilated vessels (telangiectasis)
appear upon the surface, and after some time, inflamed sebaceous follicles
(acne papides and pustules) appear. (3) The third stage involves con-
siderable hypertrophy of the connective tissue elements of the skin,
leading to the formation of nodules (rhinophyma) which are sometimes
of great size. Rosacea runs a prolonged course ; the first stage alone
may extend over many years.

The Diagnosis is not difficult, except in its early stage, when the ery-
thema may be mistaken for lupus erythematosus and other kinds of
erythema of the face (§ 462). The former, however, is recognised by
slight scaliness ; and a lens reveals the presence of a fine '* tissue-paper "
surface (see below).

The Causation of the disease is not understood. It aSects both sexes,
but in the female sex is particularly apt to start at the evolution and

1 Lancet, August 1, 1896u

§§i60, 461 ] LOCALISED ERYTHEMATOUS ERUPTIONS 649

mvolution of sexual life — i.e., when the vaso-motor system is particularly
irritable. Among males, it is specially apt to afiect cabmen, coachmen,
mariners, and others who are exposed to the weather. Drink is a frequent
and potent cause, but the disease may arise in total abstainers. It is
often associated with constipation, dyspepsia, and pyorrhoea.

Much of the Treatment of acne vulgaris (§ 463) is available for rosacea.
The cause, if possible, should be removed. In the first stage stomachics,
alkaline carbonates and other internal remedies are indicated. Several
cases under my care have benefited by large doses of calcium chloride.
Calamine lotions and soothing remedies should be applied. In the later
stages, diligent application of phenol at intervals, and for rhinophyma
scarification, will undoubtedly ameliorate even very bad cases.

I 460. II. LapiiB Erythematosni (Synonyms : Ul-erythema Centrifogam, SeborrhoBa
Gongestiva of Hebra) is the most ohronio of the erythemata. The eruption has a
spreading eiythematous border, which as it spreads leaves a very thin permanent scar
io the centre. In the first stage the disease begins with one or more small, red,
slightly -raised spots. By spreading at the margin and increasing in number the little
patches form, in the course of many months, an irregular bluish-red area, with thio
cicatricial centre and erythematous margin covered with scales, and sometimes with
crusts. In another variety (scborrhoaa congestiva of Hebra) there is a marginated
erythema with numerous black specks, or large gaping openings of the sebaceous
glands ; the central part of the skin appearing depressed, and covered with adherent
dry scales, interspersed with venules. The favourite seats of the eruption are the
cheeks and bridge of the nose (butterfly distribution) ; then other parts of the face
and forehead, the lips, ears, scalp (where the scar leaves permanent bald patches),
the extensor surfaces of the hands, fingers, and toes (1. pernio), and more rarely on
other parts of the body. The patches are generally symmetrical. In rare oases the
er3rthematou8 patches become rapidly widespread over the body, and severe con-
stitutional symptoms are present.

Etiology. — The disease is much more frequent in women than men, and very rarely
occurs under twenty, a most important circumstance in the diagnosis from lupus
vulgaris, which invariably appears before or during adolescence. Lupus erythema-
tosus, according to some observers, is connected with the tubercle bacillus, but this
has never been found in the lesions. The Diagnosis from lupus vulgaris is given in
tabular form (§ 490). Before cicatrices appear it may be hard to distinguish from
Rosacea. Prognosis. — L. erythematosus extends over ten or twenty years ; always
terminates in cicatricial changes in the skin, and permanent baldness of a hairy part.
Beyond the disfigurement the disease is not serious, and is unattended by constitu-
tional symptoms. The acute disseminate variety usually terminates fatally.

Treatment. — In the early stage we must employ soothing remedies which act super-
ficially {vide acute eczema). If these fail, stimulating ointments and caustics may
be necessary, such as salicylic and carbolic ointment, or salicylic collodion, or plaster
mull. Painting with carbolic or oarbol-camphor, or sulphur pastes, etc., give rise to
a reactionary inflammation and swelling which runs its course in a few days, then
results in considerable improvement. Linear scarification, X rays, high frequency,
zinc and copper cataphoresis, and Finsen treatment have also given satisfactory
results. Internally, quinine, salicylic acid, and intestinal disinfectant treatment
have given good results.

$ 461. III. Erythema Nodosum is an eruption with an acute onset, consisting of
erythematous lumps about the size of a pigeon's egg, occurring most frequently over
both shins. The patches are roimd, oval, raised, non-marginated, painful, and tender.
The centre is most deeply coloured, whence the purplish tint gradually fades away to
the margins. There is usually some malaise and elevation of temperature ; some-
times pain in the joints and other rheumatic symptoms. Each nodule lasts one to
two weeks, and sucoessive crops may continue for a month or two. They never

660 THE SKIN [ § 462

uloerate. Patients are usually young women with a rheumatio diathesis. The con-
dition is known from other forms of erythema by the position of the lesion and the
acute pain and tenderness. In periostitis the lesion is usually single. The disease
usually runs a benign course to spontaneous recovery in a month or two. The Treat'
metU consists in the administration of salicylates, saline aperients, and after the acute
symptoms have subsided, iron and quinine internally. Lead and opium lotion applied
locally allays the pain.

§ 488. IV. Certain specially named forms of erythema may be men-
tioned.

Erythematonf Eciema. — Eczema is usually vesicular, but there is an eiythematous
variety which may run its course without presenting any vesicles. The surface of
the skin is red, d^, and rough, with slight scaling. It £requently attacks the face,
when the eyes may be almost closed, and is attended by burning and itching. For
treatment, see Eczema, § 478.

X-ray Dermaiitii may be acute, consequent on a single large dose, or chronic, after
repeated small doses of X rays. In the acute form there is erythema, swelling,
sometimes bullae, and sensations of burning or intense pain, according to the degree
of the mischief. In mild chronic cases there is temporary loss of hair and pigmenta-
tion. If exposures are continued, telangiectasis develops ; atrophy, cracking of the
skin, warts, and indolent ulcers follow. Treatment is prevention by ensuring greater
protection to those engaged in X-ray work by wearing lead foil or other material
impervious to the rays. Sedatives, lotions, and pastes hasten the recovery of acute
dermatitis. Antiseptics should not be employed. For chronic forms it is neceasaiy
to order complete rest from exposure to the rays.^

Bedioref (E. paratrimma) are due to pressure over prominent parte, such as the
sacrum, trochanters, heels, or ankles of the bedridden, or to the pressure of a badly-
adjusted splint. A local patch of erythema appears, followed by abrasion of the
skin. If the cause continues sloughs form. They are due to three causes : pressure
or irritation from rubbing, perspiration and excretions in cases of incontinence, the
lowered vitality of the sick and aged. In certain nerve diseases, especially myelitia,
the sloughs form so rapidly that the condition is attributed to a trophic neurosis.
Extreme foetor attends the decomposition of the slough, and septicaemia may set in.

TretUment. — Good nursing can prevent bedsores. Three principles should be kept
in mind : cleanliness, dryness, and relief of pressure, (i.) The parts should be care-
fully cleansed night and morning, and the draw-sheet pulled through immediately it
becomes soiled, (ii.) After washing, the skin should be thoroughly dried by rubbing
over a little methylated spirit or brandy, and well powdered, (iii.) Belief of pressure
is obtained by a water-bed, ring pads, and by frequently turning the patient from
side to side. If an ulcer or slough forms, these measures should be combined with
the plentiful use of antiseptic lotions, and occasionally a charcoal poultice to relieve
the pain and promote healing.

Brythema Faciei vel e, fugax is a flushing cf the face which occurs chiefly in asso-
ciation with dyspepsia. It may form the first stage of rosacea. E, traumaiicum
develops on any part subject to long-continued pressure — e,g,, the garters and tight
waist-bands. E. lave is the erythema found on the legs of dropsical persons. E,
caloricum appears on the face from exposure to the sun and wind. E. intertrigo is
foimd in parts which are opposed, such as the thighs and armpits, in infants, corpulent
people, or those who perspire much. It may pass on to eczema. E. pernio (Synonyms :
dermatitis congolationis, frostbite, chilblain) is a painful inflammatory condition of
the skin of the fingers, toes, heels, or other portions of the feet or hands, caused by
exposure to cold, and attended with itching and tenderness, sometimes by vesication,
ulceration, or gangrene. In the form of the so-called chilblain it is prone to ocour
in those whose circulation is poor, and constitution feeble. Thus children and old
people frequently suffer from this complaint during successive winters. Treatment
consists in local applications of stimulating liniments, such as iodine and camphor,
and internally, iron and strychnine.

^ Hall Edwards, Brit. Med. Joum., vol. ii., 1908, p. 720.

§ 468 ] PAPULAR ERUPTIONS 651

Pellagra is a non-oontagious disease (f onnerly endemic) ooourring in adults in parts
of Italy, Spain, and the I^rol, due to eating diseased maize, and charaoterised by ery-
thema, vesicular and bullous eruptions, pigmentation, atrophy. The disease at first
appears in spring and ceases in the winter ; later it persists throughout the year. The
eruption appears first on parts exposed to the sun. There are stomatitis, dyspepsia,
aqji nervous symptoms, sensory, motor, and mental, with progressive constitutional
weakness. It terminates fatally in five to fifteen years.

lUoQlar Leproiy appears as brownish or mahogany-red patches of erythema of
various sizes ({ 491).

c. Eruptions which tisuaUy consist of Papular Elements,
Common, Rarer,

\ VI. lichen planus.
VII. Keratosis pilaris and foUiculans.
Vni. MiHum.
IX. Lichen scrofulosorum.
X. Adenoma sebaceum.

I. Acne vulgaris and other forms of

acne.
II. Prurigo.

III. Scabies.

IV. Papular syphilide.
V. Skin diseases, sometimes papular at

(me stage :

(i.) Papular eczema.

(ii.) Psoriasis and other scaly

eruptions,
(iii.) Exanthemata,
(iv.) Pustular and vesicular

diseases,
(v.) Erythematous eruptions,
(vi.) Noidular eruptions.

§ 468* I. Acne Vulgaris is an eruption consisting of ** blackheads " or
comedones and indurated papules which may go on to suppuration, con-
fined to the face, shoulders, and back, and sometimes the chest. Acne
papules are pale red to crimson, and hard (A. indurata), varying in size
from a pin's head to a small pea. These are invariably accompanied by
a number of black points (comedones), which are black plugs of sebum.
The papules come out one after another, and are remarkably persistent ;
some go on to pustulation, or the formation of small abscesses, leaving
scars if untreated. The skin of the face in individuals afiected with acne
is usujftlly greasy, coarse, and dusky-looking.

Causes, — The disease in a considerable proportion of cases starts soon
after puberty, and fresh papules may continue to appear for some years,
occasionally to middle life or old age. Inspissated sebum blocking the
follicles is the histological cause of the papules, and the change which the
hair and sebaceous follicles undergo at puberty appears to be one of the
factors in the causation of disease. Sabouraud and other observers have
found a bacillus, which they consider the causative factor. Indigestion
undoubtedly aggravates the condition.

Varieties. — (1) Acne punctata, A, ithdurata, and A. pustulosa are stages
in the diseased process, not varieties in the true sense of the word. (2) Asso-
ciated with pit3rriasis of the scalp a crop of papules often appears on the
face, almost identical with acne spots, excepting that they are smaller,
softer, and not totally accompanied by comedones. Its favourite posi-

662 THE SKIN [ § 464

tions seem to be the chin, the furrows below the angles of the mouth,

and sometimes between the scapulae. (3) Bromide and iodide acne are

indistinguishable from each other, and the individual spots resemble acne

vulgaris very closely. Comedones, however, are absent, and there is a

greater frequency of distribution over the chest and back, though the

face is always first afiected. (4) Acne Rosctcea is mainly an erythema, afc

any rate in its earlier stages (§ 459).

5. Acne varioliformis is a severe variety of A. pustulosa. It occurs chieHy on the
brow, and is apt to leave deep soars. 6. A. cachecticorum (Uebra), or A. scrofulo-
Borum (Colcott Fox ^), or A. necrogenica is another pustular variety affecting chiefly
the back and the extensor surfaces of the limbs, and to a less degree the face, in
debilitated or scrofulous children. It is now regarded as a tuberculide. It differs
markedly from A. vulgaris in its distribution, and though it may last for many years,
is generally amenable to tonic treatment and cod-liver oil. It is liable to be mistaken
for a syphilide, but the latter is less indolent, and there is a firmer infiltration.

The Diagnosis of acne from the other eruptions in this group is not
usually difficult on account of (1) its characteristic position, and (2) the
presence of comedones. Papular, pustular, and tubercular syphilides
afiecting the face are usually copper-coloured, and grouped in a ser-
piginous manner. Lupus vulgaris generally occupies one side of the face
and presents no comedones.

TreatmerU, — If there be much irritation soothing applications are best
applied at first — e.g., calamine lotion. Of all remedial agents sulphur is
the most efficacious. A sulphur ointment (20 to 40 grains to the ounce)
should be rubbed on night and morning, or a sulphur lotion, or resorcin
in strengths varying according to the skin of the individual. For pus-
tular acne mercury is indicated, as in all suppurating afiections — e.g., an
ointment of 10 to 30 grains to the ounce. To prevent scarring an anti-
septic lotion should be used, each pustule must be lanced, and its interior
wiped out with a pointed stick or match dipped in pure carbolic or camphor
phenique. Staphylococcal vaccine injections are of value when crops of
pustules resist ordinary treatment, and acne bacillus vaccine suits other
cases, and is used alone or in combination with the staphylococcal vaccine.
The scalp should always be examined for seborrhoea, and, if necessary,
treated, for unless this be cured, the acne may recur. Indigestion and
constipation aggravate acne, and must be corrected. Washing the face
frequently with warm water and soap, rinsing o5 the soap, and rubbing
with a rough towel is a valuable domestic remedy. X rays and high
frequency currents have been found useful in some cases.

§ 464. II. Pmrigo is a disease in which the leading and sometimes the
only symptom is generalised itching (pruritus), but it is frequently accom-
panied by an eruption of papules, urticarial patches, and scratch-marks.
The papules of idiopathic prurigo are hard, shotty, acuminate, pale red,
frequently better felt than seen (giving the sensation of a nutmeg-grater),
come out in crops chiefly on the extensor surfaces of the thighs and arms,
the trunk, especially the back and buttocks, and only occasionally the

1 Lancet, 1895, vol. ii.. p. 499.

i 464 ] PRVBiao 863

face. Each crop lasts a week or two, and is sometimes accompanied
by urticarial blotches ; dermatographia can generally be elicited. The
intense itching leads to scratch-marks. In the course of time prurigo is
followed by a dry, rough, thickened, pigmented skin. The Prognosis is
unfavourable, especially in the very
poor, the disease recurring tor years,
and sometimes lasting for life.

The Diagnosis is simple in well-
marked cases by the intensity of the
itching and the condition of the skin.
The eruption of prurigo very closely
resembles that of scabies (§ 465) and
pediculi corporis (Fig. 129), but in
scabies it is almost oonHned to the
fesMTts of the joints instead of the
extensor surfaces ; in pediculosis to
the iack and shoulders, where it is
attended by typical staining. The
pmriginous eruption of pediculi pubis
(Fig. l-W) is more or less localised.
The diagnosis from papular eczema
is not always easy ; eczema, however, generally prefers the flexures and
flexor surfaces, while prurigo predominates on if it is not confined to the
extensor aspects.

Varieties. — (I) Frorigo inf^ntftlia (Synonyms: Urticaria Papulosa,
Lichen Infantalis, Lichen Urticatus, Prurigo Mitis) should, in the author's
opinion, be classified aa a variety of
prurigo. Thd papules are small, chiefly
on the back, and the urticarial element
moderate. It starts about the fourth
month of life, and recurs until about the
fourth year. (2) In P. adolenentinitt
the papules are larger, the urticaria
promineut, the skin brown and thickened.
(3) In P. senilis (Synonym : Pruritus
Senilis) the eruption may be insignificant
or absent, and the irritation intractable,
with a tendency to induration and
purpuric complications, (i) In "-pTun-

ginous" eczema, an eczema complicates ^«- ""^^Tn't^' °"^"'"'
a prurigo ; (5) In P. agrius, the prurigo

of Hebia, all the lesions are on a larger scale, the inguinal glands
involved, and the general health deteriorated, (6) Summer prurigo
(Synonym : Lichen netivalis) develops in hot weather, and the papules
tend to vesicnlation and scarring (hydroa vacciniforme) ; and (7) P.
hiemalie occurs in cold countries or in the winter onlyt

654 THE SKIN ( } 4W

Etiology. — Prurigo ia especially apt to occur at the two extremes of
life, aQd ie probably a blood disorder with irritability of the cutaneous
nerre endings.' Irritation of the alimentary traot is liable to start out*
bursts of the disease, which is greatly influenced by improper food, and
unhealthy surroundings. It may be idiopathic, or secondary to scabiee
or pediculi. The idiopathic causes of prurigo are the same ae those of
pruritus (§ 450c).

Treatment. — The first indication is to discover the cause, for without
oarefuUy sifting this question no treatment can be successfully carried
out. One must first exclude phtheiriaais, scabies, or other parasites.
Then determine whether there is any other source of local irritation, such
as an unbleached cotton or flannel garment, or an acrid discharge ; and
iinaUy turn to the idiopathic causes. Warm weak tar baths should be
taken night and morning, followed by the inunction of a mild tar or
mercury ointment, to get the skin into a healthier condition, and the softest
of undergarments should be worn. For local itching, carbolic acid 1 in
40, allcaline lotions, vinegar, chloral- camphor {^li. of each liquified and
added to 3i. starch powder) are all useful. The diet should be plain;
sugar, alcohol, and excess of meat must be avoided. Any digestive errors
should be corrected, and the possibility of mncous (catarrhal) colitis borne
in mind. Calcium chloride in large doses has been very efficacious in my
experience. Other remedies which are worth a trial are — oaimabis indioa,
antipyrin, valerian, belladoima, bromides
(especially in nervous subjects), jnlo-
oarpin, liq. am. aoet., atropine, carbolic
acid, salol, salicylic acid, and other in-
testinal antiseptics.

§ 465. III. SoaUei is the eruption
produced by the acarus scabiei. It con-
sists of papules and vesicles of varying
sizes ; the latter may go on to the
formation of pustules. In addition to
its multiform character, it is readily
diagnosed in its typical form (1) by the
short white or black burrows ; (2) by

Fig- ISi.— AOARUS SoABin ((enwlal, ,, ■ -■ i.- j i i_ i

iDBCaiflsd about twentr urnei. The Cue excessive itcning, and Boratcn-marks ;

!S"4i,"Sr b'SSi.'"ttS"l.m'^ 1-5) ty *» '">* "at it «lw.y. oommenoM

bdng qoUe ^niiai aod biMk with tha and predominates where the »lrin is

to«ei at Um iDMOt : niMt frequently ^. ■ V. . i ^ .i. e

iitoMad on Uia wiiit. Th« mkie rokini ttunnest — i.e., between the fingers or

!?^?^iSS^' """ °^"'"' """ to». ttie flexures of the wrists and

elbows, the axilUe, the penis, the inner

side of the feet and thighs ; (4) by a history of contagion ; and (5) lastly,

by the discovery of the animal or its eggs (Fig. 131). Prurigo ia

likely to be mistaken for scabies, but prurigo predominates on the

§ 466 ] PAPULAR 8 YPHILIDE 666

extensor surface and outer side of the limbs. Eczema is perhaps the
disease with which, in the adult, it is most frequently confused. Many
experienced physicians have overlooked the parasitic origin of eczema
thus produced, and it is a good rule to suspect scabies in inveterate
cases of eczema. Scabies untreated may go on for an indefinite
time, but it readily yields to treatment. Sulphur ointment should be
thoroughly applied after a warm bath with plenty of soap, for at least
four successive nights, and the underlinen and sheets should be boiled.
Balsam of Peru, either pure or mixed with equal parts of vaseline, is a
more expensive but equally efficacious remedy. If the sulphur produce a
secondary eruption, mix it with equal parts of zinc ointment.

§ 466. IV. Papular SsrphiUde. — Syphilitic eruptions are often multiform,
but papules generally form the most prominent feature of all syphilitic
rashes, especially in the secondary stage. The papule, indeed, forms the
prototype of all syphilitic eruptions. These papules are firm, glistening,
and project above the surface of the skin with a hard, infiltrated margin,
and vary in size from a pin's head to a bean. They are of a brownish-red
colour (like copper or raw ham) which does not entirely disappear on
pressure. The wide variability in the size of the papules is a feature dis-
tinguishing this from other papular diseases. As they increase in size the
centre often becomes depressed, or cupped. The distribution is more or
less generalised, often symmetrical, but the favourite sites are the fore-
head, around the mouth, the flexor aspects of the arms, and the trunk;
When near the comers of the mouth or the anus their surface may be
moist, and the secretion is highly infectious, no matter how long after the
contraction of the primary malady. Itching is rare. Other constitu-
tional signs of syphilis may be present. The presence of shotty glands
in the groin and neck and elsewhere is a valuable aid in the diagnosis of
all syphilitic eruptions. They are present even when no other signs are
present, and may last throughout the patient's life. Two varieties of
papular syphilid e are described according to the prevailing size of the
elements, papular syphUide if the spots are small and nimierous, lenticular
syphilide if they are large and scanty. The former is met with more in
the early, the latter in the later stages of the diseases. Large, moist, flat
papules, usually seen near the anus, are called condylomata. Rarer forms
are the corymbose syphUide, in which there are clusters of very small
papules surrounding a central larger papule ; and small papules resembling
lichen pilaris, follicular syphilids The latter is very obstinate ; mercurial
vapour baths may be necessary (see also §§ 404: and 489).

V. Skin Diseases sometimes Papular. — Eczema Papulosum (Papular
Ezcema, Pruriginous Eczema) is a term which should be confined to
papules which rapidly pass on to vesiculation, or which are associated with
definite patches of eczema. Papules frequently form a stage, generally
an early stage, in psoriasis, seborrhcea, pityriasis rubra pilaris,
SYCOSIS, in the exanthemata and erythemata, and in xanthoma and
UBTICARJA pigmentosa. These are dealt with in their respective places.

656 THE SKIN [ §§ 467-469

Rarer Papular Diseases.

§ 467. VI. Lichen Plannf (Synonym : Lichen Ruber Pianos) is an eruption con-
sisting of flattened, angular, shiny, dull red papules, often presenting a central depres-
sion, and a greyish stria tion on the surface. These tend to coalesce and form irregular
patches of a peculiar purplish hue. Occasionally rings are formed (lichen annularis).
There is no exudation. When the papules disappear much pigmentation may be
left behind. The eruption is frequently symmetrical, and by far the most character-
istic positions are the flexor aspect of the wrists and forearms, and the inner side of
the knee. Sometimes the distribution is more generalised, and the mucous membrane
of the mouth may be affected. Itching as a rule is present, and may be troublesome.
By the fusion of several papules large plaques may be formed, and when these take
on a warty growth, as about the ankles, the condition, which is very intractable, is
called lichen verrucosus. Lichen occurs mostly about middle age, and has been
noticed to appear when there is a degree of nervous debility. In Vienna two-thirds
of the patients attacked are males (Kaposi), aged ten to forty ; whereas in England
the majority of cases occur in women. There should be no difficulty in diagnosing
lichen planus from a papular syphUide or an eczema, on account of its tjrpioal position,
angular shape, purple colour, and flat waxy surface. The Prognosis as to the cure
of the condition is good under treatment, although this may have to be extended
over many months. The eruption remains localised to definite regions for years, but
may become generalised. The Treatment consists in the administration of arsenic
and tonics internally, and local soothing applications, such as F. 90 or 93 (see also
§ 499). Some recommend small doses of hydrarg. perohlor.

§ 468. VII. Keratosis Pilaris (Synonjrms : Pityriasis Pilaris, Lichen Pilaris or Spino-
sum) is an affection of the skin, generally of young adults, in which the orifices of the
hair follicles of the thicker portions of the skin — i.e., on the extensor and outer sur-
faces of the limbs — are occluded with corneous plugs. Hard friction, with almost
any ointment at night, and a rough towel in the morning, will generally remedy the
condition in a few weeks.

Keratosis FoUicolaris (Synonyms : Darier's Disease, Psorospermosb) is a very rare
disease, due to overgrowth and degeneration of cells in the mouths of the pilo-sebaoeous
follicles. The papules are at first of pin-head size, resembling keratosis pilaris.
They contain in the centre a homy plug, which is difficult to remove. Some become
enlarged and hypersDmic ; others become confluent, presenting a papillomatous
surface covered by hard yellowish crusts. Tlioso may ulcerate, and the area may be
covered with a mucopurulent discharge. The disease affects first the fooe and head,
and after the gradual development of years appears over the sternum, spine, loins,
hypogastric and inguinal regions, and the extremities with symmetrical disposition.
The Diagnosis may be difficult, in the early stages, from keratosis pilaris and ichthyosis,
and in the later stages from acanthosis nigricans. Treatment consists in the use of
salicylic, sulphur, or other keratolytic applications.

§ 460. Three rare conditions — Milium, Lichen scrofulosorum and Ade-
noma sebaceum — come under the papular rashes.

Vm. Milium. — The term milium is applied to an eruption of small whitish or
yellowish pearly granules about the size of a pin-point, which affect chiefly the delicate
skin under the eyes, the eyelids, cheeks, temples, scrotum, and labia. It is due to
retention within the sebaceous follicles, owing to an overgrowth of the stratum cor-
neum closing their openings. Some say they consist of embryonic tissue. The
Treatment consists in making a small incision over the granule, and squeezing out
the contents. Or electrolysis may be employed.

IX. liohen Scrotalosomm is an eruption of minute yellowish-red papules, isolated
or grouped, and occiirring usually on the breast, abdomen, or back- of tuberculous
subjects. They are painless, and do not itch. It is not common after the age of
twenty. It is not serious, and may last, hardly noticed by the patient, for months
or years, and then subside without leaving a trace behind it. Its treatment is that
of other tuberculous affections.

J 470 ] PSORIASIS 667

X. Adenoma Sebaoeam is a rai'e disease, consisting of numerous small hemispherical
elevations, discrete, grouped usually about the middle of the face. In size they vary
from a pin-head to a split pea. Their surface is crimson or pinkish yellow, and asso-
ciated frequently with telangiectases. They have no visible orifice. Some disappear
spontaneously, leaving a small scar. The disease is almost always congenital, though
it may not be observed till puberty, when it takes on fresh activity. It is said to
be associated with intellectual inferiority, but this is not always the case. It is due
to overgrowth of the sebaceous glands and hair follicles. The knife, electro-cautery,
or electrolysis are necessary to destroy the growths where spontaneous involution
does not occur.

d. Eruptions usuaUy Scaly or Scurfy.

Common. I Barer.

I. Psoriasis. I VI. Exfoliative dermatitis.

II. Seborrhcsic dermatitis.

III. Tinea ciroinata.

IV. Scaly syphilide.
V. Skin diseases sometimes scaly at one

stage — e.g., eczema, lichen, ery-
thematous diseases.

VII. Pityriasis rosea.
VIII. Pityriasis rubra pilaris.
IX. Ichthyosis.
X. Erythrasma.

§ 470. Psoriasis is a commou disease, occurring as irregular patches,

slightly raised, covered with copious silvery scales, unattended by any

exudation, and situated chiefly on the elbows and knees. The lesion

starts as a tiny papule (P. punctata) which from the first has on the top

a scale, which, however, may not be visible till scratched. The papule

gradually enlarges (P. guttata). In a short time it reaches the size of a

coin (P. nummularis). The disease generally then remains stationary for

some weeks or months, and may tend to undergo spontaneous involution.

The healing process usually starts at or near the centre, and gives to the

eruption a circular or serpiginous appearance (P. oircinata, P. gyrata).

The lesion is scaly and elevated from the first, and always dry, three

features which at once distinguish it from eczema, and if the top scale is

scratched oft bleeding hypersemic papillse are exposed. The distribution

is extremely characteristic, being found always on the knees and elbows,

frequently on the scalp, trimk, and other parts of the limbs, especially the

extensor aspects, and only very rarely on the face, palms, or soles. There

is little or no itching or subjective symptoms. Psoriasis of the nails

causes pitting, ridging, and elevation of the free border.

Causes. — As regards age, the disease is most frequent in early life,
though rare under seven years. Both sexes are equally affected. There
is a considerable hereditary predisposition in some families. The seasonal
influence varies in my experience, but those who are subject to the malady
often complain that it recurs each winter or spring.

Diagru>sis. — It is important to distinguish psoriasis from scaly syphUide,
and in many cases the character of the lesion affords no true guide. A
syphilide has more infiltration ; rarely affects the elbows and knees, and
generally prefers the flexor aspects, and palms, and soles ; the centre of
the patches are usually depressed, stained, and healing; the scales are
scantier, less silvery, and on being scraped off, do not leave bleeding-

658 THE SKIN [ § 471

points. ** Seborrhceic dermatilis^^ is sometimes difficult to differentiate
from psoriasis, and, indeed, Unna (the describer of the disease) holds
that they are identical. The seborrhoeic patches are less crimson, the
scales smaller, scantier, greasier, and more orange coloured ; they occur
by preference on the shoulders and upper parts of the trunk, and if affect-
ing the limbs are usually on the flexor aspects. The scalp may be affected
in both diseases.

Prognosis, — Psoriasis is apt to disappear and to recur spontaneously
at certain seasons. The patient may take little heed of the disease unless
it affect the uncovered parts. In severe cases the eruption may spread
over the whole body and cause an exfoliative dermatitis.

TfeatmerU, — Frequent bathing, followed by removal of the scales, is an
essential part of the treatment. Chrysarobin (J to 1 drachm to the ounce)
is the most valuable remedy, but the objection to its use is that it stains
the linen and the skin, and frequently sets up a scarlatiniform dermatitis.
For intractable cases chrysarobin paint — 20 per cent, in chloroform — may
be painted on once a week, and covered with a layer of collodion. Other
stimulating applications, such as tar, carbolic acid, and salicylic acid, are
often quite as efficacious. Plaster mulls of the same ingredients, or of
mercury, are useful. Kemoyal of scales from the scalp may be very
difficult, but must be enforced. In protracted cases the patient should
be detained in bed during treatment. X-rays often clear up a few obstinate
patches, but cannot be used for widespread disease. Internal medication
is often useful. Thyroid extract does good where other evidences of
athyroidism exist. Arsenic, cod-liver oil, salicylates (Crocker), and
copaiba (M'Call Anderson) are reconunended. Salicin I find good in
those cases where psoriasis guttata spreads more or less acutely over the
whole body. Arsenic is given only in chronic cases.

§ 471. II. Seborrhoeic Dermatitis (Svnonyms : Seborrhoeic Eczema ;
Pityriasis Circinata) was first described by Unna. It occurs in irregular
ovoid patches, greasy, covered with brownish-red scales ; quite superficial,
sometimes slightly raised, with sloping margins. They sometimes heal in
the centre, forming a ringed eruption which may be mistaken for ringr
worm. The patches vary in size from a small pea to a crown piece, or
larger. Single papules may be present, brick-coloured, and soft, espe-
cially on the face. The disease is foimd chiefly on the scalp, whence it
may spread on to the forehead and face, then on the sternum and back of
the neck and shoulders. It is often limited to the upper part of the
body, but the lower parts of the body may be affected, and the legs
occasionally present typical patches. The affection is more frequent than
is generally thought, being often diagnosed as ordinary eczema when from
irritation or other causes it passes on to an eczema with vesicles and
crusts. It is frequently associated with psoriasis ; Unna considered the
two diseases identical. The disease is more frequent in, though not con-
fined to, young people. It is undoubtedly contagious in the author^s
experience, and is particularly apt to spread to those who occupy the

478] SQUAMOUS SYPHILIDS 659

same bed and whose pillows are apt to be exchanged. Professor Unna
ascribed it originally to the bottle bacillus, Dr. Sabouraud to the staphy-
lococcus griseus acting in conjunction with the bottle bacillus.

Diagnosis. — The scales of psoriasis are more silvery, and on removing
them hypercemic bleeding papillae are seen ; in seborrhoeic eczema minute
points of oozing serum may be seen on removing the moist scales. The
two diseases may coexist ; hence probably the confusion.

The Treatment must not only be directed to the cure of the patches
which are on the body, but to the scalp, for imtil this is cured the erup-
tion will constantly recur upon the body. A pomade of hyd. ox. rub.
(7 to 10 grains to the oimce) should be rubbed in twice a week, or a lotion
of hyd. perchlor. (1 grain to the ounce). Sulphur and oil of cade are
equally efficacious (see also § 498).

Epidemic Peri-oral Eciema. — In 1895 the author had the opportunity of investi-
gating an eruption which occurred on the faces of a large number of children in one
school in the East End of London. The school contained nearly a thousand children,
and quite half of these were affected in succession during three or four months. The
patches occurred mostly around the mouth, on the face and neck, and rarely else-
where. They were superficial, reddish, dry, scurfy, ovoid, somewhat resembling a
superficial seborrhoeic dermatitis. They were supposed to be ringworm, but this was
positively excluded. The disease readily yielded to a mild tar and mercury ointment.
It certainly spread from child to child, but only one of the teachers was slightly affected
{British Medical Journal, 1896, vol. i.).

III. Tinea Circinata may appear as small red patches, of an oval or
ringed shape, slightly scaly. When the head is afEected with the small
spored ringworm, these patches may often be seen on brow, neck, and
shoulders. Another variety, due to the epidermophyton inguinale, forms
scaly patches and rings on the thighs and groins. The diagnosis is made
by finding the fimgus in the scales (see § 480). This form used to be
described as eczema marginatum.

§ 472. IV. Squamous Syphilide (Syphilitic Psoriasis). — The squamous
syphilide occurs as a later stage of the papular or the tubercular syphilitic
eruptions (q.v.), and does not constitute a separate form of eruption of
itself. It is recognised by the fact that the scales are thin, scanty, and
greyish, lying upon patches of stained and infiltrated skin (i.e., the syphi-
litic papules) which are deep brown or copper coloured, usually round, or
in the shape of segments ofcirdeSy having raised serpiginous scaly borders.
A squamous syphilide may occur on any part of the body, but the flexor
aspects and the palms or soles are particularly characteristic situations,
the converse of psoriasis vulgaris. A scaly syphilide of the palms is
diagnosed from dry eczema by its raised serpiginous border, with some
times an area of normal, atrophied, or pigmented skin in its centre.

V. Certain skin diseases are scaly at one stage. A scaly or scurfy condition of the
skin, especially of the face, is produced by hard water and exposure, and in certain
states of ill-health. It is also met with after scarlatina, measles, and some of the
other eruptive fevers. In eczema, which is a somewhat protean disease, scales and
crusts form, but the presence of exudation is its essential and differentiating quality.
Ptiyriaaia capitis is a scaly or scurfy condition of the scalp, sometimes called also
seborrhcBa sicca, or dandruff (see Diseases of the Scalp). In several varieties of lichen,

660 THE SKIN [ $§ 47S-476

a thin eilvery scale is constantly found, although they belong really to the papular
eruptions. This occurs also in papular syphiiidc, and it is difficult sometimes to
draw the line between a papular and a scaly syphilide. Lupus eryihemaloaus is
attended by adherent scales and crusts.

S 478. VI. ExfoliatiTe Dermatitis. — Much discussion ranges around the use of this
term and the term Pityriasis Rubra, which has been employed by some as a synonym.
It is best to regard the term £zfoliatiye Dermatitis as implying any chronic or sub-
acute generalised inflammatory disease of the skin, whether primary or supervening
upon other cutaneous disturbance of long standing, which is characterised by hyper-
aemia of the entire surface, and ahundarU and repecUed ezfoHation of the cuticle, accom-
panied usually by shedding of the hair and nails. There is usually some constitutional
disturbance, and the itching may be severe.

Etiology. — (Occasionally, as a secondary affection, it may follow psoriasis, eozema,
pityriasis rubra pilaris, pemphigus foliaoeus, and seborrhoeic dermatitis. As a primary
condition the disease is of considerable gravity. It starts in several different ways,
though a rapidly spreading hyperemia of the integument is common to all. My
belief is that the different varieties which have been described as separate diseases
only differ in their mode of onset and etiology. In the Treatment of the malady
general tonic and other internal treatment, as a rule with stimulants, occupies a
prominent position. Externally soothing baths and ointments should be used.

An epidemic ezfoliatiTe dermatitis which the author first had the opportunity of
observing in 1891^ illustrated very well the wide varieties both in the severity and
other features of this malady. One hundred and sixty-three cases occurred among
the patients in the Paddington Infirmary, with a case mortality of 12*5 per cents
That the disease was epidemic and contagious was certain, that it was microbio
seemed probable, though the author's later observations on epidemics at other work-
houses and infirmaries tend to show that the milk consumed by the patients was m
eome way the means of propagating the disease amongst them, possibly having under-
gone some toxic or fermentative change.

f 474. VII. Pityriasis Rosea consists of numerous pink patches, slightly raised and
pea-sized, and oval-shaped rings, with slight scaling on the pink margins, and a fawn-
coloured centre. A " herald patch " usually appears on the trunk some days or
even weeks before the generalised eruption, which comes out in successive crops,
starting usually on the sides of the tnmk, and spreading to the neck, upper arms,
and thighs. It is rare on the face. Slight itching may be present. Pityriasis rosea
runs a course of a few weeks to a few months, and disappears spontaneously. The
disease occurs in both sexes, and at any age, but is most frequent in young adults.
It is believed to be of parasitic origin. S^orrhoRtc eczema has greasy scales and dif-
ferent sites. Tinea circinata occurs in fewer patches, and the fungus can be found.
Psoriasis has more infiltration and diffuse scaling. Syphilitic roseola has a darker
colour, and is infiltrated.

Treatment. — ^Mild ointments of sulphur or salicylic hasten the course of the disease,
and soothing lotions are useful if itching is present.

§ 476. VIII. Pityriasis Rubra Pilaris (Devergie), Lichen Acuminatus or Lichen Ruber
(Hebra), is a somewhat rare disease in which the eruption commences as tiny hard
papules of hyperkeratosis involving the hair follicles, which become fused together
into one reddened surface, and shed a succession of flaky scales. The distribution is
fairly characteristic, as it starts where the lanugo hairs are mostly found — ^namely,
the backs of the hands and forearms. In this way it often presents a glove-like
distribution on the upper and lower extremities, which is very characteristic. It
may spread over the whole body. The progressive margin is always marked by the
same tiny scale-capped papules. The disease has to be diagnosed from psoriasis
on the one hand, and dermatitis exfoliativa on the other. It is differentiated from
psoriasis by its distribution and by the presence of the little papules at the maigin
of the eruption, but is indistinguishable from dermatitis exfoliativa when the whole
body is involved, except by the large flakes ot epidermis in the latter. In the earlier
stages dermatitis exfoliativa does not present the small acuminate papules which
constitute the elementary lesion of P. rubra pilaris.

1 *' Monograph on Epidemic Skin Diseases/' U. K. Lewis, London, 1892 ; Med. See.
Trans., 1891 ; Brit. Med. Journ., December, 1891.

476-478 ] GROUP IL^VESICULAR ERUPTIONS «61

The Causes are obeonre ; the disease usually occurs before the age of twenty-one.
The malady may occur in varying degrees ol acuteness. Some oases are ushered in
with a certain degree of constitutional disturbance* vomiting, and some pyrexia, and
after lasting a few months will tend spontaneously to subside. In mild cases there
are no constitutional symptoms, and the disease runs a prolonged course of many
months. Treatment, — When it occurs in the chronic form arsenic is a remedy of some
value. The same rules guide us as in the treatment of psoriasis.

{ 476. IX. Ichthyoiii (Synoujrm : Xeroderma) may be defined as a congenital con-
dition of the skin, characterised by an undue dryness and scaliness of the epidermis,
and in some oases by the formation of wart-like outgrowths. Though congenital,
the condition may not be identified till the child is some years old.

There are three diniccd types or degrees of the affection. In the first or mild type
(Xeroderma) there is simply an undue harshness or roughness of the skin, and conse-
quently through life a great tendency to the supervention ol *' chaps," eczema, and
other skin affections. It occurs chiefly on the extensor aspects. In a second type
(/. vera) the superficial layers of the epidermis are thickened, and appear stretched ;
the hardened cuticle presents fissures and cracks which, bounding polygonal areas,
give to the patient the appearance ol a fish or crocodile skin. .The everted eyelids
and nostrils, the atrophied hair and nails, and the hardened, scale-like condition of
the skin are characteristic. In the third variety (/. hystriz, I. sebacea, PapiUoma
lineare), the skin presents a thickset aggregation, of little homy, wart-like processes
which entangle the dirt, and present a brownish-black coloration. These are arranged
in streaks, which were believed to follow the course of certain nerves, but a closer
observation shows that this is not so, the disease being a developmental one. The
diagnosis is not difficult owing to the congenital nature of the malady. Apart from
the inconvenience and the liability to eczema, the first tjrpe is not serious. In the
second tjrpe the disease progresses to the age ol puberty, and then remains stationary.
The third t3rpe rarely shortens life, but is a disfiguring malady. No known remedy
influences this disease. Vaseline, lanolin, baths, and various ointments may soften
the skin, and remove the superficial scales to some extent. Thyroid seems to control
milder cases to some extent.

§ 477. X. Brythrasma consists of defined scaly discs of a pale red, yellow, or dark
brown colour. The scales can be scraped off, and are found to contain a fungus, the
microsporon minutissimum. The patches are extremely chronic, and are found on
the opposed surfaces of the scrotum, thighs, axillsB, and mamms. They itch when
perspiration is excessive.

GROUP II. VESIOULAR AND WEEPING ERUPTIONS.

Moist eruptions, in which the elements are usually vesicular and the exuda-
tion serous, are commonly classed into those with small vesicles (I. to VIII.
below), and those with vesicles of larger size, bullae (IX. to XI. below).

I. Eczema.
II. Impetigo contagiosa.

III. Herpes.

IV. Varicella.
V. Scabies.

VI. Tinea circinata (sometimes).
VII. Sudamina.

VIII. Hydrocystoma.

IX. Dermatitis herpetiformis.
X. Pemphigus.
XI. Epidermolysis Bullosa.

XII. Pustular and other diseases in
which vesicles and bullsB may
occur at some stage.
Note. — Syphilides are practically
I never vesicular.

§ 478. I. Eezema is a catarrhal inflammation of the skin, running some-
times an acute, sometimes a chronic course, presenting a red excoriated
surface denuded of its epithelium and more or less covered with crusts,
associated in its acute stages with non-marginated swelling. " Weeping "

662 THE SKIN [ § 478

,e.f a serous exudation wliicli stifiens linen, is the chief characteristic
of eczema. Although eczema has been defined as a vesicular disease, it
may present different appearances at different stages of its course. In
eczema are seen, at different stages, the three primary and three secondary
lesions of the skin — erythema, papules, vesicles, crusts, scales, and fissures.
In the first stage, or acute eczema, there is erythema, with papules and tiny
vesicles, which readily rupture, causing a serous exudation. By the time the
physician sees the case — e.y., in a day or two, the second or subacute state
is usually reached, with excoriations and crusts, and the involved patch of
skin presents a more or less swollen surface, denuded of its epithelium. If
the disease passes on to the third or chronic stage, the discharge decreases
or disappears, leaving a thickened, irregular, scaly patch, fading at its
margins. Any part of the body may be affected, and to any extent ; but
eczema has a predilection for the flexor aspects of the limbs and the
fiexures of the joints. The patient complains of a burning, smarting,
throbbing, or itching, in proportion to the acuteness of the process.

The Diagnosis of eczema is not difficult. '' Seborrhosic dermatitis " has
no serous exudation, and is covered by greasy yellow scurf. SyphiUdes
never resemble acute or subacute eczema, or, indeed, any vesicular disease,
a fact of considerable value in practical diagnosis. It is difficult some-
times to distinguish patches of dry chronic eczema from psoriasis, but the
latter affects characteristic localities, preferably the extensor aspects, and
is covered with silvery white scales. The diagnosis of the numerous
varieties will be given below.

The history or evidence of a cause should be sought. (1) Local Causes.
— Eczema is the lesion most fiequently following the dermatitis produced
by local irritants, such as a mustard plaster, turpentine, the leaves of
certain plants {e.g., the primula obconica), or soaking the hands in water
containing soda. Eczema forms around the eyes treated with eye-drops ;
and excessive sweating may produce the condition. It often occurs around
the mucous orifices from which an irritating discharge issues (the nose,
ears, anus, etc.), and under these circumstances is very intractable. The
local hypostatic congestion attending varicose veins is a frequent pre-
disposing factor. Unrecognised scabies or pediculi lead to protracted
cases of eczema of multiform character. (2) Cor^titutional Causes. —
Eczema may occur as a complication of dyspepsia, gout, diabetes, or renal
disease. In cases of eczema of the vulva or prepuce, the urine should be
examined for sugar, and the presence or absence of leucorrhoea ascer-
tained. It often accompanies albuminuria, especially if dropsy be present.
It may appear during every pregnancy, or after the cessation of lactation,
when neuropathic influences are at work.

Varieties. — In addition to the typical acute and chronic forms described,
there are several varieties of eczema. (1) In E. papulosum the process
stops at a papular stage. (2) E. pustulosum or impetiginodes is due to a
secondary invasion by pyogenic cocci, occurring frequently on the heads
or faces of children, on the hairy parts of delicate and tuberculous persons,

§ 478 ] ECZEMA 663

or when any local irritation is present ; it is attended by the formation of
crusts. (3) E. rubrum occurs usually on the legs, chiefly in old people,
where the deficient circulation produces a livid colour, and prevents repair.
(4) In Vesicular E, the vesicles are prominent, tend to come in crops, and
become confluent. Its favourite localitias seem to be the face, the ears,
and the flexures of the limbs, fingers, and toes. Some cases of this disease
resemble dermatitis herpetiformis. (5) E, squamosum is a chronic scaly
stage into which many erythematous and papular varieties develop, and
is found most frequently on the palms, legs and scalp, and is apt to be
mistaken for psoriasis and squamous syphilide. (6) Occurring in different
parts of the body, eczema is often named from the locality — E. capitis,
E. ani, E. intertrigo, but it is unnecessary to invent special terms for
these varieties, except, perhaps, in the case of E. j>almarisy which is often
due to the sufferer's occupation (baker's itch, washerwoman's itchy etc.).
(7) In the palms it is apt to become chronic, dry, thickened, and fissured
{E. rimosum),

(8) Gheiro-pompholyx is the term given to a vesioular and bullous eruption afiFecting
the hands symmetrically, and sometimes the feet at the same time. The thickness of
the epidermis in this situation prevents the rupture of the vesicles. Those are espe-
cially prone to appear in the clefts between the fingers and toes, like boiled sago grains,
and creep on to the palmar and dorsal surfaces — an important diagnostic feature
between this disease in its later stages and a scaly syphilide of the palms. Some of
the vesicles coalesce into bulliB, their contents become absorbed, and exfoliation of
the epidermis occurs.

(9) E, Marginatum is tinea circinata of the groins and genitals (§ 471).

(10) Pagei's disease of the nipple is really a malignant form of eczema. It starts
on the nipple of one or both mammas, and spreads centrifugally, sometimes with a
slightly raised margin, leaving a reddened, congested, and sometimes weeping surface.
It is met with mostly in females of advancing life, and it consists of a slowly-growing
cancerous process.

(11) Peri-oral Eczema (§ 471) is a term which was applied by the author to an
epidemic condition which he observed in a large board school in 1895.

The Treatment of eczema differs materially according to the stage of
the disease. The principles of treatment are those underlying the treat-
ment of all diseases of the skin. In the acute inflammatory stages, when
there is much erythema or vesiculation, the indication is rest indoors or
in bed if necessary, with such soothing applications as zinc oxide, calamine,
lead, or bismuth, especially in the form of lotions, powders, and occa-
sionally ointments. Lead and weak creolin lotions are comforting ; and
for acute eczematous conditions I have found nothing more successful
than the prescription F. 42, or lot. calamin. co. Saline aperients are useful ;
and vin. antimon. n\^x. with mag. sulph. J dr. t.d., if used early, seems
sometimes to out short the disease. A daily bath (say a teaspoonful of
creolin to 15 gallons of warm water) is indicated whenever the eruption
is widespread, and among out-patients in whom want of cleanliness is a
potent causal factor. In subacute stages a stimulating agent should be
added to the soothing remedy ; and in the chronic stages change of air
(to hilly country in preference to seaside) and stimulating remedies.
These are tar, mercury, resorcin, creosote, carbolic acid, salicylic acid,

664 THE SKIN [ § 478

and sulphur. But a mere knowledge of the drugs to be employed is not
sufficient ; it is necessary to follow certain rules in their application.
Thus for weeping surfaces lotions, not ointments, should be chosen ; for
thickened surfaces ointments should be not merely smeared on, but
rubbed in or spread on a piece of lint, and firmly applied to the skin, so
that a macerating effect may be obtained. The same results may be
obtained and the part protected by the use of medicated plaster mulls,
the most useful of which, perhaps, is a weak tar and mercury plaster
(4 per cent, of the former and J per cent, of the latter). It is of no use
to apply remedies over thickened crusts or scabs ; these must first be
removed by means of bread or starch poultices, or wiped away with olive
oil. When the surface is thus cleaned it must be kept aseptic by ex-
cluding the air and renewing the applications every four hours for acute,
and once or twice a day for chronic, conditions. Lotions should rarely
be covered with gutta-percha tissue to keep them moist, because the part
becomes sodden. Eczematous parts must never be washed with soap and
water, but when ointments are used, they may first be cleansed with
sweet oil or creolin lotion (1 drachm to 1 pint). In the latter stages an
ointment containing mercury or tar may be used (e.^., F. 104), the stimu-
lating agent being cautiously increased. If there is much secretion an
astringent lotion (such as lead or creolin) may be first employed to cleanse
the part, while if the part is dry and scaly, the tar and mercury may be
increased without danger. In cases of long duration in which consider-
able thickening exists, our chief object should be to remove the products
of disease so that the healthier underlying structures may resume normal
growth. This may be done by the active application of exfoliating
remedies such as salicylic acid (20 to 30 grains or more to the oimce)
and sulphur. In very inveterate cases the previous application of strong
plaster mulls (e.gr., salicylic acid 10 to 30 per cent, and creosote 10 to 40
per cent.) facilitates the process, though it may at first appear to make it
worse by setting up an acute inflammation. Tonics and internal remedies
should be administered, such as iron, alkalies and gentian, etc., to correct
any morbid general condition ; arsenic should seldom be used except in
chronic non-inflammatory cases. In the intractable eczema affecting the
extremities of the aged, I have found small doses (I to 3 minims) of opium
of great use. Constitutional treatment is specially indicated when the
eruption is widespread or generalised. The digestion must be put in
order, and when there is any marked tendency to erythema or congestion
three remedies are of great use — alkaline carbonates, quinine, and calcium
chloride, all in fairly large doses.

Treatment of Varieties. — E. of the eyelids requires careful treating, lest
the ointment should set up conjunctivitis. The following ointment —
hyd. ox. flav. and acid, borici, aa gr. ii., aq. dest. and ol. amyg. dulc.
aa ni^xxx., lanolin 1 oz. — may be found useful. For eczema around
mucmis orifices, the great indication is to keep them dry, and a powder
consisting of equal parts of zinc oxide, bismuth, carb., and calamine

479] HERPES 6«5

frequently dusted on gives relief. Calamine lotion is also useful. For
E, jMjmlosum a creolin bath and the removal of the offending garment
suffices ; for E, impetiginodes ung. hyd. am. is almost a specific ; cheiro-
pompholyx is treated on the same lines as acute E. ; in J&. palmaris gloves
saturated with the ointment should be worn at night, and if possible by
day, and a small quantity of ointment should be smeared on after every
washing ; PageCs disease is an indication for removal of the breast (see
also § 499).

II. Impetigo Contagiosa consists of discrete vesicles of varying size
which soon become pustular (§ 484).

Staphylococcal and streptococcal skin infections give rise to many
different kinds and sizes of vesicular eruptions of the impetigo class,
which may be mistaken for eczema or herpes on the one hand, and pem-
phigus or urticaria bullosa on the other.

§ 479. III. Herpes (Synonyms : Herpes Zoster, Zona, Shingles) may
be defined as an acute non-contagious disorder, consisting of one or more
dusters of vesicles on a crimson base, associated with neuralgic pain, and
due to an irritative lesion of one of the ganglia of the posterior spinal
roots or their analogue the Gasserian. Herpes commences with a red
patch or a group of flat papules, on which vesicles very rapidly appear.
The vesicles are larger than those of eczema, round, hemispherical, and
uniform in size, about as big as a millet seed ; and as there is no tendency
to spontaneous rupture there is usually no oozing such as occurs in eczema.
They smart or bum, and the neuralgic pain which precedes and follows
the affection is often very severe and intractable. The vesicles contain
clear serum, and after lasting a few days, dry up and form little crusts.
The whole attack lasts on an average three weeks. The vesicles leave no
ulceration and no scars. The affection is nearly always unilateral.
Formerly a patch of herpes was thought to correspond with a sensory
nerve distribution, but the groups correspond more precisely with what
is known as a sensory area ; that is to say, an area which has been shown
by Mackenzie, Thorbum, and Head to represent the terminal distribution
of the pain-appreciative (algetic) fibres connected with each spinal seg-
ment (§ 558). Many varieties are named according to their position —
e,g,, H. frontalis, ophthalmicus, brachialis. H.febrilis (facialis or labialis)
often accompanies inflammations of the respiratory tract. H. progeni-
talis, or preputialis, which occurs on the genital organs of both sexes,
sometimes alarms patients with the dread of syphilis. Serious varieties
are zoster hcBmorrhagums, in which haemorrhage occurs into the vesicles,
and zoster necrogenica in which the skin sloughs, and is followed by scarring
or keloid. Diagnosis, — Herpes may be distinguished from all 6ther
vesicular conditions by the occurrence of the vesicles in dieters or con-
stellations and their erythematous base. In regard to Prognosis, herpes
tends to spontaneous recovery in the course of a few weeks, except in the
two grave forms above mentioned. The neuralgia which succeeds, how
ever, is often very intractable, especially in the aged.

THE SKIN

[S«

The Treatmertt is quite aimple. Protect the vesicles by starch or zinc
powder, or paint with collodion, or use some soothing ointment. Quinine
in large doses, 5 grains three or four times a day, is reputed to be the beat
remedy for the neuralgia. For herpes preputialis give lead lotion.

IV. V&ricella, the description and differential diagnosis of which has
been dealt with (5^ 352 and 355).

Table op Diaqnosis.

No aymptoma before rash.

Soft pink papules boooming vesicular.

Cbrat, neck, and trunk, rarely face and

BaooHiJve orapt, and thus find small
papules besides vesieles o£ varioos

Small-pox.
Throe days before rash, sudden onset ■

illnoBs with backache.
Shotty papules becoming vesioular c

Firat on face and arista
legs in regular order.

All one itwe (papular
pustular) at one plam

then trunk and
or vesioular. or

V. Scabi«B is chieHy a papular eruption (§ 465). But in children the
vesicular element b apt to predominate, and it may then be mistaken for
varicella. The burrows, and
the marked tendency which
scabies has to affect the soft
skin at the bends of the joints
and between the fingers should
obviate such a mistake.

§ 480. VI. Tinea Circinsta,
or ringworm of the body, is
occasionally vesicular, especi-
ally when occurring on the
wrists of adults, the arrange-
ment of the vesicles in the
form of a definite ting being
BO characteristic as to be un-
mistakable {Fig. 132). The
usual naked-eye appearance of
this lesion is a pale red ring
with a BCTirfy margin. With a
lens the margin b seen to be
slightly raised with minute
papules or vesicles. When
*''*>'mcI7«?''l1I^*\"hX^"SS^''S?rnJn^i■i originating from the horse

nnmuBlly 'prominent. A tamo ring of vaides there may be dlstiuct SUppUra-

SDCkMM a acurly area, Verifleil by mlcroBFonic .. n>, , .. • i-.-

eitaniiaition. tion. The favourite localities

are the face, neck, and arms.

When occurring in the genito-crural region, it used to be (improperly)

called eczema mai^inatum (and see g 471). On examining scrapings under

S5 481, 482 ] DERMATITIS HEBPETIFORUIS 667

the microscope, the mTOelium (Pig, 133), and perhaps a few spores of
the tricophyton tonaurans (the large-spored fungus, g 498) can be seen.
The treatment consists of
rubbing in ung. hyd. amm.
chlor., OF some other parasi-
ticide.

i 481. VII. Sndimina arooletU'.
scattered . non-inflamniBtarj
vesiolea. like dropjeta of water,
abont the size of n pin's head,
oooumng in oonditions such m
Mute rheumatism, which are
attended by very profuse per-
apiration . They do not give riao
to any inoonvenionoo, aod dis-
appear in a few dayn. They are
a not) -inflammatory disorder of
the sweat glands, whereas
miliaria (ooromonly called priokly
heat) h a mildly inSammatory
oondibion of the same glands
obaraoteHsed by similar papules
and vesioles on a red base.

VIII. HrdrODTstoma ia a rare ^ll' 133.— Hycttliam ol Tinra Ciroinata irlngworm ol

disease ohsraoferised by deep. I!'Aw.''^l;7^^ "^mEI;;?,,.'""^ "" i''''"' "?T* i""^

, . , . , . . ."^ Gram B method. MyceUumotequalaegmsntohavInd

aeated. tenae. tiaQsluoent vesiolea tmniuUd enda bllurcatlnn la places ; sporei aimoat

ooourring on the faee. vu-ying in absent. Compare Fig., i 4flH.

size from a pin-head to a pea, very

persistent, lasting for months. They are formed by a cyatio swelling of the duct of
the sweat-gland, and never become purulent. They disappear spontaneously, chiefly
In cold weather. The disease occurs chiefly in middle-aged women, especially in
those whose life is spent in a warm, moist atmosphere, or who perspire much. It
frequently comes on aa warm weather sets in. The Trfotmenl oonsists in puncturing
the VBsiclea.

g 482. IX. Dsimatitli Herpetitormi* ia the term ni<ed by Diihring' for a large and
ividely varying group of eruptions which were formerly classed under pemphigus and
various other headings.' Dermatitis herpetiformis may be defined as a relapsing
disorder of prolonged duration, characterised by the appearance of successive orope
of erythematous or papular elements, always in clusters, which usually go on to the
formation of vesioles, pustules, or bulla, are always attended by intense irritation,
and sometimes by pigmentation. Different varieties are described according to the
element which predominali^s. In some [the eryWtevuiloiu variety) the preponderating
eruption oonsistfl of oiroumscribed patches of bright red erythemateus or semi-urti-
oarial inflammation, which spread by raised edges, and leave a pigmented centre.
In another, and perhaps a commoner variety (the papiUo-veeicaiar), vesicles which
vary from the size of a pin's head to a split poa prcdominat-o. Sometimes these
veajelea become bullie as big as a walnut (the buUous variety). They arc always in
clustels of two or three, and may coalesce, and sometimes the vesicles become pua-

' American Journal of lAe Medical Sciencee, February. 1891, and elsewhere ; also
New Sydenham Society's publications.

' Synonyms of Dermatitis Herpetiformis : Pemphigus pruriginosus ; pemphigus
oircinatoB (Rayer) ; pemphigus compost (Devorgie) ; herpes gestationis (Milton, 1S72) ;
herpes oiroinatus bullosus (Wilson) ; herpes pMyctenodes (Gilbert) ; erythema bullo-
aum ; dermatitis multiformis (I^Sard) ; hydroa gestationis (Liveing) ; hydroa herpeti-
forme; hydroa bullosus ; pemphigus arthritique (Bazin); Duhring's disease; impetigo
herpetiformis of Hebra ; dermatite polymorphs prurigineuse, ou douloureuse, chronique
k pouBsiea succeasives (Biocq).

668 THE SKIN [ § 488

tular. The fluid in the bullae contains eosinophil cells in great excess, and this is
true also of the blood. Sometimes the predominating element is a papular one, and
because of the itching the heads of those become scratched, and covered with blood-
stained scabs. Still more often these various elements are commingled, for the
different lesions apparently represent different stages of the same pathological prooess.
The intense itching is a very notable feature in all the varieties, especially the papulo-
vesicular one. Scars and temporary pigmentation may ensue. In many oasas the
general health seems undisturbed, but often the appearance of each crop is attended
by pjrrezia, and occasionally gastro-intestinal disturbance. As regards its distribu-
tion, the elements have a tendency to be symmetrical, and to favour the flexor surface
of the wrists, the axillae, groin, abdomen, and buttocks. The mucous membrane of
the mouth and pharynx may also be involved. Each successive crop last^ from one
to four weeks ; each attack being separated by longer or shorter intervab of com-
parative freedom. In this manner the disease may go on for months or years.

Diagnosis, — ^The disease differs from pemphigus vulgaris in the following respects :
(1) The smaller size of the vesicles or bullae, which are (2) constantly arranged in
clusters ; (3) the presence of erythematous patches beneath the vesicles and else-
where, and the multiform character of the eruption ; and (4) the presence of itching.
Nevertheless it will be seen that all these differences are more questions of degree
than of kind. From eczema, urticaria buUosa, and erythema multiforme the disease is
distinguished by consideration of the above features.

Etiology. — ^The disorder is more common in men than in women, and between the
ages of sixteen and thirty. Many regard it as a dermato-neurosis, by reason of its
symmetry and tendency to attack neurotic individuals.

Treatment. — Arsenic is of great service, and should be given in full doses. Quinine
and salicin, and phenacetin for the irritation are useful. Locally, sedative lotions
and ointments may be prescribed, much the same as those recommended in acute
eczema (q.v.), while Duhring advocates sulphur ointments, 2 drachms to the ounce,
and tar lotions — e.g., liquor carbonis detergens, 5 drachms to the pint.

§ 488. X. Pemphigus is one of the rarer diseases of the skin, characterised by the
presence of bullae and constitutional symptoms of a mild or severe nature. P. chronieue
or vulgaris is the more common and t3rpical variety in which the bullae develop in
crops, each bulla var3ring in size from a pea to a hen*s egg, being tense with clear fluid,
which becomes turbid, purulent, and occasionally haemorrhagic (P. haemorrhagicus).
The bulla is characterised by having no ring of erythema round its base. The fluid
is either absorbed with formation of crusts, or the blebs burst, leaving a raw surfAoe
on which new epidermis soon develops. Almost any part of the skin may be afi^ted,
as well as the mucous membrane of the mouth and nose. While each bulla only lasts
a few days fresh crops may continue to come out for several months. The constitu-
tional disturbance depends largely upon the number of bullae and the frequency of
the crops, the prognosis for recovery being good when the number is small, and grave
when abundant. Many cases are apt to recur throughout life. A malignant type is
described by G. Pemet and W. Bulloch, following a wound or a bite. There is high
fever and extreme prostration, with death in one to three weeks. A diploooocus is
found in the bullae. In P. foliaceus the bullae are very thin and flaccid, and rupture
early ; but the epidermis, instead of re-forming, continues to peel off until large areas
of red, raw, exuding surface are exposed, with epidermis folded at the margins — a
point which distinguishes it from eczema rubrum. This process slowly extends for
a year or two untU the whole body may be involved, and a fatal issue ensues. P.
vegetans is a rare variety, which develops papillomatous vegetations on the base of
the bullae, and usually ends fatally in a few months. The Etiology is obscure. It is
more frequent in infancy, and is about twice as common in the male (Kaposi). At
different times pemphigus has been associated with renal disease, anomalies of the
female sexual organs, and lesions in the spinal cord or 83rmpathetic system. Con-
tagion has often been suspected, and various observers have found bacteria in the
bullae, but the etiological value of such findings is not established. The treatment
of pemphigus is usually regarded as rather hopeless ; but arsenic in gradually increasing
doses in some cases seems to have quite a specific action. Quinine 'and other tonics
and a generous diet are called for. especially in cachectic cases. Opium is good in

§ 484 ] GROUP 111.— PUSTULAR ERUPTIONS 669

P. vegetans. Among local remedies the continuous bath in severe oases, and dusting
powders or boraoio ointment to protect from septic influences in milder cases are
the best.

X. Epidermolysis Bullosa is a rare congenital disease in which slight traumatism
causes the formation of bullae. It usually runs in families. The bulls? appears on
parts exposed to friction or pressure. I have found ergot useful ( A.F.S.).

XI. The description of the other diseases occasionally characterised by
vesicles or bullae — erythema multiforme, urticaria, drugs, congenital
syphilis, leprosy, etc., will be found imder their respective headings.
Frequently streptococcic infection of the skin gives rise to large bullae.

GROUP III. PUSTULAR ERUPTIONS.

Eruptions in which the elements are mainly pustular naturally faU into

three classes.

a. Superficial Pustules.

I. Impetigo contagiosa.
II. Ecthyma.

h. Pustules on an Indurated Base.

III. Pustular syphilide.

IV. Sycosis.

V. Pustular acne.
VI. Pustular folliculitis.
VII. Bromide and other drug eruptions.
VIII. Variola.
IX. Acute glanders.
X. Pustular tuberculide.

c. Furuncular Eruptions with a Slough.

XI. Boils.
XII. Carbuncles.
XIII. Kerion.

Hebra wrote in 1870 " all pustules must be regarded as secondary morbid products,
and hence are not fitted to form an independent series of cutaneous diseases.** Curiously
enough almost the only exception to this dogma is to be found in that rare condi-
tion Impetigo Herpetiformis, which was first described by Hebra. Eczema and all
the diseases mentioned in Group II. may become pustular, owing as we now know to
infection by pyogenic cocci. Conversely, nearly all the pustular diseases just
mentioned may start as vesicles.

According to Dr. Sabouraud (the Lancet, August 10, 1901, p. 403, and Brit. Med.
Joum., August 3, 1901), there are three prevailing cocci found in the skin. (1) The
streptococcus which is the cause of the impetigo contagiosa of Tilbury Fox, and for
this he recommends I or 2 per cent, zinc sulphate ; (2) staphylococcus aureus, which
invades the follicular orifices and causes pustules, being the cause of all primary and
secondary pustular lesions, and for this he recommends sulphur 19 grammes, alcohol
30 grammes, aq. rossB 100 grammes ; and (3) staphylococcus griseus, which causes
pityriasis simplex and seborrhoeic dermatitis, and is the same as the morococcus of
Unna. For this he recommends oil of cade 10 grammes, yellow binoxide of mercury
1 gramme, and pet. moll. 30 grammes. All these three organisms Dr. Sabouraud
suggests are probably polymorphic varieties of one and the same microbe.

a. Swperficial Pustules.

§ 484. I. Impetigo Contagiosa (Synonym : Porrigo) is frequently met
with on the faces of children, and is so called because it is readily conveyed
from one child to another. At first the spots are vesicxdar, but they become

670 THE SKIN [ § 484

pustular in a few hours. The pustules vary in size, and are discrete, but
may run together if near each other. In the course of a few days they dry
into yellow crusts, which, falling off, leave a flat congested mark covered
by new cuticle. They do not leave scars unless scratched. The favourite
positions are the face, especially round the mouth, scalp, and hands of
children, but they may occur on any part of the body. If untreated, fresh
pustules appear in other places for a week or two ; or the disease may die
out spontaneously in a few weeks. It is usually trivial, without constitu-
tional disturbance, and with only slight itching. The disease may be con-
veyed by contagion to other parts of the same or to another individual.

Etiology. — Impetigo will spread through a school or family of children,
attacking weak and strong alike. Adults enjoy remarkable immunity,
but occasionally an adult will contract it from a child. The essential cause
is a streptococcus. Coccal infections of this class may give rise, as just
mentioned, to vesicular and vesico-pustular eruptions of several kinds.

Diagnosis, — Impetigo pustules are readily distinguished from acne,
sycosis, pustular syphilide, and all other pustular eruptions by (i.) their
superficial character, and (ii.) their typical localities.

The Treatment is extremely simple. The crusts must first be removed
with warm water, a little sweet oil, or a starch poultice ; and then a few
applications of sublimate solution, or ung. hyd. am. chlor. are sufficient.
Mercury is almost a specific in pustular affections.

Eczema impetiginodes is really a pustular form of eczema as already
described.

Impetigo Herpetiformii, or, as it might be more properly called, PYiEMio Impetioo.
is a rare disease described by Hobra, the differentiation of which from dermatitis
herpetiformis is often difficult. It is a pyaemic process of the skin, characterised by
the appearance of clusters of miliary pustules, usually starting on the inner surface of
the thighs, whence they spread to almost the entire integument, generally associated
with the pregnant or puerperal state, and terminating fatally. The tongue, palate,
pharynx, and even the oesophagus have been the scat of pustules and superficial
ulceration. There is considerable fever of pyaemic type, with delirium and vomiting,
and each fresh crop of pustules is attended by rigors and increasing prostration. Ail
but two of the recorded cases have been connected with the later months of pregnancy,
and if the patient recovers from the tirst attack the disease seems to be apt to rocur
in a subsequent pregnancy. Nearly all the recorded cases have terminated fatally
sooner or later.

The Treatment should be conducti'd on the lines of other septicsemias. Vigorous
local measures should bo employed ; probably the acid nitrate of mercury vigorously
applied in the early »tagc might cut the process short. But when the disease is estab-
lished it would perhaps bo better to make hourly applications of 1 in 1,000 corrosive
sublimate. Any vaginal or uterine discharge should be attended to by frequent
irrigations.

II. Ecthyma is a term which is gradually falling into disuse, but is still sometimes
used to describe larye isolated pustules, or the superficial sores which form part of
impetigo, scabies, pediculosis, etc., in children and aged persons broken down in
health, and wanting in piTsonal cleanliiioss. They may have to be distinguished from
scabies in children and from suppurating syphilides.

III. Diphtheria of the skin resembles a widespread, obstinate impetigo, with large,
sometimes sanious crusts, and is usually diagnosed by the discovery of the microbe
after the disease has resisted ordinary treatment for impetigo. Injections of anti-
toxic serum readily cure the lesions.

§§ 485. 486 ] P UST ULA R S YPHILIDES—8 YC0S18 67 1

6. Pustules on an Indurated Base:

§485. III. Pustular Syphilides are of two types : (1) Small PajnUo-pus-
tvlar Syphilide (Acneform Syphilide, or Lichen Syphiliticus Pustulosus)
consists of spots about the size of a pin's head, upon a hard base, which
in a week or ten days scab off, leaving the characteristic indurated papules
with depressed centres. They are arranged in groups, circles, or circular
lines. (2) Large Pustular Syphilide (Rupia, Ecthymatous Syphilide,
Variola Syphilitica) consists of pustules varying in size from a split pea to
a halfpenny, flat or hemispherical, and surroimded by a raised brick-red
infiltrated margin. They may be grouped, ringed, or isolated. The
pustule bursts, the pus escapes, and crusts are formed with ulceration
beneath them. The ulceration tends to spread serpiginously, and leaves
permanent scars, rings, and pigmentation. Both varieties may occur on
any part of the body, and both indicate a malignant type of syphilis.
The smaller pustular syphilide may have to be diagnosed from acne by the
presence of comedones, and slower course in the latter. When on the face
pustular syphilide may be hard to distinguish from lupus vulgaris, but the
youth of the patient in the latter complaint, and the extremely slow rate
of progress, may aid us. When pustular syphilide is diffuse, it may be
mistaken for variola, but in the latter there is a history of a vesicular stage,
of backache, and constitutional symptoms.

§ 486. IV. Sycosis is a term applied to a slowly growbig papulo-pustular
eruption affecting the sebaceous glands and hair follicles of the beard and
sometimes the moustache. Indurated papxdes at first appear, and some
of these undergo suppuration. The disease is usually contracted at the
barber's shop, but may be taken from horses and other animals suffering
from ringworm. Clinically there are three conditions which present the
appearance which we describe as sycosis (a-uKoi/ = a fig). (1) True Sycosis
(Synonym : Folliculitis Barbae) in which the pustules become large and
indurated, and in this later stage the hairs can be easily drawn out, fol-
lowed by a drop of pus. This is due to staphylococci, and on that account
is sometimes called coccogenic sycosis. It is usually contracted at the
barber's, or it may be due to a nasal discharge. (2) Tinea Sycosis
(Synonym : Hyphogenic Sycosis) is ringworm of the beard due to the
trichophyton tonsurans. The large spored ringworm in children, and the
ringworm of horses, cows, cats, and dogs may produce this disease. There
are two varieties : (a) Superficial, characterised by scaly red rings, in which
the hairs are only slightly involved ; and (b) deep-seated, in which hard
nodules and lumps are formed with suppurating hairs. In this form the
bail's are easily pulled out from the onset. (.*)) Eczetna barbw taking on
suppuration consists primarily of a general infiaumiation of the skm with
pustules around some of the hair follicles secondarily. In true sycosis
the pustules are the predominating element, and the intervening inflam-
mation is secondary. In eczema barbae the eczematous condition affects

672 THE SKIN [ §§ 487. 488

the intervening parts, and spreads on to the face as well. All tliree con-
ditions may, if untreated, last for a considerable time.

It is sometimes very difficult to diagnose which of the three conditions
named we have to deal with ; unless the trichophyton be found. In tm-
petigo contagiosa the pustules and crusts are quite superficial and readily
distinguished from sycosis. The Treatment is prolonged. The hair should
be kept short. Salicylic and carbolic acids and mercury are, in my ex-
perience, the best reagents to use. Vaccines may be tried. Epilation by
X rays is the most rapid method of cure. The eczematous variety b
treated like other eczemas (§ 478).

§ 487. Various other pustular eruptions may be mentioned :

V. Putolar Aone is recognised at once by the presence of comedones, papules, and
pustules on the face, and sometimes the upper part of the back. This and the severe
pustular form known as acne varioliformis is described in § 463.

VE. Poitnlar Follioolitif is a papulo-pustular condition specially affecting the hair
follicles, due to a pyogenic infection (staphylococcus aureus, according to Sabouraud).
It is independent of eczema, and affects only the hairy parts, especially the legs in
men. It may be distinguished from a syphilide by the fact that each papule or pustule
involves a single hair follicle.

VJl. lodidei and Bromidei sometimes produce pustular eruptions on a congested
indurated base. Antimony, aconite, arsenic, sulphide of calcium, nitric and salicylic
acids also produce pustular eruptions.

VIII. Variola (SmaU-pox).— The concluding stage of the eruption in this infectious
fever is another illustration of pustules forming upon an indurated base (§ 355).

IX. The eruption of Acute Glanderf when it has reached a pustular stage is so much
like small-pox that it may very pardonably be mistaken for it (§ 362).

X. A pustular Tuberculide is described by some observers as a rare manifestation
of tuberculosis.

c. Pustular Erupions from to become Furuncidar, or Sloughing :

viz,, Boil, Carbunde, and Kerum.

§ 488. XI. A Furuncle, or boil, is an acute, circumscribed, suppurative
inflammation in the skin, varymg in size from a small pm's head to a bean.
When the process fails to pierce the skin it is called a blind boil. As a rule,
however, the inflammation involves the surface, which breaks and permits,
in the course of a few days, of the discharge of the central necrosed portion,
which is spoken of as the core. The cup-shaped cavity which is left heals
by granxdation, and a scar remains. The pain is considerable, especially
in the early stages, and varies with the tension of the part. A specially
severe form of boil is the " cadaveric boil," which is due to infection during
a post-mortem examination. Furunculosis is the term applied to the
condition in which boils are constantly recurring over a prolonged period
at different parts of the body.

Trea^men^.— Protect the part from external irritation. Frequent
ablution is necessary. Hot carbolic compresses relieve pain and hasten
r«50very, and a weak tar or ichthyol ointment may be employed. Iron,
strychnine, and sulphuric acid are useful, and the general nutrition should
be improved. Vaccine treatment has been successful, and high-fre-
quency currents abort boils.

1489] FURUNCLE 673

XII. A Carbuncle may be regarded as a combination of several boils side by side,
constituting an inflammatory area of considerable size spreading beneath the skin,
with numerous openings in the skin through which the pus pours. A leathery slough
forms as it were a sheet in the deeper layers of the derma. Its commonest position
is the neck or back, but it may occur on the sacral region from pressure, on the face
(when a neurotic element can generally be traced), or elsewhere. The patient is nearly
always advanced in years, and is often lowered in health in some way. The pain and
constitutional disturbance are often very severe, and if the carbuncle be extensive
general pyssmia may ensue, or death from exhaustion. The Dio^no^M is never difficult,
on account of the characteristic red, infiltrated, swollen, circumscribed area in one of
the positions named, and honeycombed appearance with pus-discharging holes. The
Gausea are much the same as those of boils, though carbuncle is more often the result
of debilitated states and diabetes, and is more often foimd in the aged suffering from
cardio- vascular disease.

TretUmerU. — Warmth is in my experience most useful to check the extension, or,
if this is impossible, to promote suppuration, and the separation of the slough. When
by unmistakable fluctuation we know that suppuration has ensued, free crucial inci-
sions should be made, the slough cut away as freely as possible, and frequent syring-
ings every hour or so with a carbolic lotion, 1 in 100, adopted. Iron, arsenic, strych-
nine, and a liberal diet should be freely administered. Vaccines are not so useful as
for boils, but should be tried.

Xin. Kerion is a condition occurring chiefly on the heads of children suffering
from ringworm, due usually to an ectothrix infection, of animal origin. Occasionally
it may also be seen in cases infected with small-spored ringworm. Superficially it
resembles a carbuncle, but without the same induration. It is a circular, raised,
inflamed, boggy area of skin through which are a number of pus-discharging holes
(see § 498).

GROUP IV. MULTIFORM ERUPTIONS.

Multiform eruptions are sometimes found in the following conditions—
syphilis, scabies, eczema, erythema multiforme, varicella, leprosy, and der-
matitis herpetiformis.

§ 489. General Characters of Syphilitio Emptions. — Syphilitic eruptions
have already been referred to under S3rphili8 (§ 404) and tmder papular
and scaly eruptions. (1) They are of many different kinds, and several
kinds may be present at one time (polymorphism). All kinds of ele-
mentary lesions may appear on the skin with the single exception of
vesicles ; eczema and other vesicular lesions are never found as a result
of syphilis — a diagnostic feature of great importance. (2) The syphilitio
pajnUe may be regarded as a prototype of a syphilitic skin lesion. It is the
starting-point of them all. (3) The features common to all syphilitic rashes
are their reddish-brown colour, generalised or symmetrical distribution,
grouping in segments of circles, preference for the forehead and flexor
aspects, polymorphism and absence of itching. The later skin lesions in
malignant cases (in which a so-called tertiary stage occurs) differ, however,
in being asymmetrical, and with a marked tendency to ulceration.

The clinical features which distinguish syphilides are explained by three histological
facts. (1) All syphilides are due to a deposit in the dermis or epidermis of a cellular
infUtrcUion. Hence the colour does not disappear on pressure, and is followed by
staining. (2) The cells constituting this gummatous or granulomatous infiltration
are of low vitality. They do not organise into connective tissue, but tend to undergo
either involution by absorption on ^e one hand, or auppuraUon and pustulation on
the other. Hence the depressed cup-shaped centre, and the great tendency to poly-
morphism. Hence also the absence of vesioulation or an cczematous form of eruption.

674 THE SKIS [ §

(3) The infiltration spreads unirifugaUy. Hence the raised peripheral edge is the
newest part, the shape most frequently assumed being that of a cresoent. oinde, or
segment of a cirole leaving a stained centre where the papule began. If these three
principles be appreciated sJl the clinical features are explained.

Scabies (§ 465), as it occurs in cbildren, is nearly always a multiform
eruption, consisting of papules, vesicles, sometimes pustules, scratch-
marks, and burrows. By the presence of the latter and the position of the
eruption the diagnosis is arrived at.

OROUP F. NODULAR ERUPTIONS AND TUMOURS OF THE SKIN.

A nodule may be defined as a solid deposit in the skin, whidi b larger
than a papule. The cammaner forms are : I. Lupus Vulgaris ; 11. Sjrphilitic
Gummata ; III. Various Benign Tumours (e.g,y sebaceous cyst, lipoma,
rheumatic nodules, vascular n£8vi, etc.) ; and IV. Epithelioma ; while the
rarer forms include : V. Leprosy ; VI. Bazin's Disease ; VII. MoUuscum
Contagiosum ; VIII. MoUuscum Fibrosum ; IX. Sarcoma Cutis ; X. Actino-
mycosis ; XI. Leukemia ; XII. Yaws ; XIII. Mycosis Fungoides ; XIV.
Blastomycosis ; XV. Sporotrichosis ; and XVI. Madura Foot.

Some eruptions usually papular may take on a nodular form — e.g..
urticaria pigmentosa, congenital xanthoma (§ 495).

§ 490. I. Lupus Vulgaris may be summarily defined as a chronic disease
of the skin, characterised by a collection of reddish-brown, semi-translucent
(** apple- jelly ") nodules embedded in the corium, which give rise to some
general thickening and desquamation, and have a tendency to ulcerate
and to result in cicatricial atrophy. Their favourite position is the face,
in which position the patches are rarely symmetrical, as in 1. erythema-
tosus. They occasionally affect the limbs — in 20 per cent, of the cases
according to Kaposi. The disease almost invariably starts early in life —
in childhood. Sometimes it is found extensively over the body, its
onset dating iisually from an attack of measles or other acute specific
fever.

The Prognosis of lupus vulgaris turns principally on three things :
(1) Its position, (2) its extent, and (3) the general condition of the patient.
Untreated, the disease will spread for years.

TreatmefU. — Greneral hygienic and tonic measures as for phthisis are
useful — e.g., good food, fresh air, malt, and cod-liver oil. Local treat-
ment consists in (1) excision, which is only applicable to a very circum-
scribed area of disease ; (2) curetting, followed by caustics or the cautery,
the result of which is often very satisfactory in a localised patch, but un
fortunately in most cases requires periodic repetition ; (3) Finsen lamp
(photo-therapy), which is best suited to limited patches and yields excellent
results ; (4) X rays (radio-therapy) ; (5) high-frequency currents ; (6) hypo-
dermic injections of tuberculin have produced good effects, and are par-
ticularly suitable for lupus scattered widely over the body ; (7) ionisa-
tion ; (8) caustics and escharotics like acid nitrate of mercury carefully
applied, carbolic and salicylic acid, etc., are extremely useful to arrest,

I«0]

GROUP V,— NODULAR ERUPTIONS

675

and even, by prolonged treatment, to cure the disease when other methods
are not available. Prolonged eicposure to bright sunlight when available
is also curative.

Nodukur Syphilide,

Table of Diagnosis.

Lupus Vulgaris.

Lupus Erythematosus.

Nodular or diffuse infiltra- ** Apple- jelly " nodules in
tion with raised edges. , derma. Sebaceous fol-
licles not specially in-
volved.

Destroys more in a month Destroys slowly and usu-
than lupus in a year. ally leaves puckered
Stellate scarring. ' scar.

Sometimes symmetrical. 1 Asymmetrical.

Adults.

First appears in childhood.

Amenable to Hg and KI. Hg and Kl do harm.

Superficial erythema. Se-
baceous follicles plugged
with hard sebum.

Never ulcerates, though
may leave a superficial
scar.

Bat's • wing distribution
on face. Generally
s ymmetrical.

First appears in middle
life.

Hg and KI no good.

II. Syphilitio Gmumata occur in the skin for the most part in the later
stages of the disease. They are met with as round or ovoid nodules in or
beneath the skin. In the course of a few weeks they usually make their
way to the surface in the form of an indolent abscess, which leaves a cir-
cumscribed punched out ulcer, sometimes of considerable depth. They
may occur anywhere, but especially on the legs, brow, nose and sterno-
clavicular region. They should not be lanced.

III. There are several other relatively common Benign Tamoars or nodules origin-
ating in the subcutaneous tissue, which may involve the skin — eg., sebaceous cyst,
fatty tumour, rheumatic nodules, fibro-neuroma, subcutaneous n»vi, and lymphangiec-
tasis. SebaoeOQi Oyst (Synonyms : Steatoma, Wen) is a tense, painless, cystic
tumour due to the occlusion of a sebaceous follicle sometimes associated with acne,
and usually single. For its eradication the capsule must be entirely destroyed.
Fatly Tamoari are known by their doughy feel, lobulation, the puckered depressions
seen on trying to lift up the skin over them. Bheomatio Hodnlei occur in successive
crops, as small, hard, or elastic nodules, sometimes adherent to the skin, usually freely
movable beneath, sometimes tender on pressure. Their favourite situation is over
the fibrous tissue of the superficial bones — ^that is to say, chiefly around the joints
and along the spine.

IV. Epithelioma* epithelial cancer, affecta the skin in three forms, and the favourite
Beat of all three is the face. 1. In the papular form it is found as hard, glistening,
pale, flat papules, which grow very slowly, become cracked, fissured, and ulcerated
(vide Uloeration). 2. The nodular or deep-seated form is less frequently met with.
It occurs as close-set, flat, or slightly raised, '* very firm and somewhat translucent
nodules. In the course of months or years it grows into a spherical or flat, hard
tumour, whose surface is shining, waxy, or rosy, traversed by vessels, irregularly
nodular. As the result of spontaneous retraction the centre is often drawn in like

676 THE18KIN [ { 411

an umbilicus ; the edges are steep and smooth."'^ Later, ulceration occurs. 3. Papil-
lomatous or warty growths {malignarU papillomata) are occasionally met with. All
three may be found in the same individual, but the first b the most common and the
slowest to grow. The favourite sites are the lower lip— at least 50 per cent. — ^the
tongue, and external genitalia. It may occur on a scar, on old lupus patches, or on a
8-jnile wart. The majority of cases occur in men. Lesions having these features
occurring in a person past middle life should always be examined microscopically,
and steps taken for their eradication.

§ 481. Certain rarer forms of nodule and neoplasm also afiect the skin.

V. Leprosy (Synonyms : Lepra, Elephantiasis Gnecorum, Leontiasis Satyriasis) is
a chronic constitutional disease, characterised by pigmentary, sensory, and nodular
changes in the skin, due to a specific microbe affecting the skin and nerves. Leprosy
used to be a widely prevalent disease, but only imported cases are now found in
England. It is still endemic in Norway, paits of Russia, Turkey, and the Turkish
provinces, and in China, India, West Indies, etc. Sir Jonathan Hutchinson believes
that the infection is conveyed by fish. It is communicable from man to man, though
its infectivity is feeble, and probably only through an abrasion of the surface. The
disease is met with in two clinical forms in its earlier stages, (a) Macvio-aruBsiheiic
leprosy, which consists of patches of antesthesia. sometimes of pigmentation or leuco-
derma, usually associated with thickening of the nerve trunk connected with the part,
and a widespread eruption of reddish spots and patches over the body. These signs
may be preceded by pain, and followed by paralysis and atrophy of the muscles
supplied by the affected nerves. (6) Nodular leprosy, in which are found small
diffuse thickenings, sometimes pink, yellowish -brown, or without much alteration of
colour of the dermal tissue and mucous membranes. These increase to form bosses,
and occurring on the face give to the patient a leonine aspect in course of time (faoios
leonis). The viscera and mucous membranes are similarly involved, and wherever
the granulomatous material is formed the characteristic bacillus is found, which closely
resembles the bacillus of tubercle. Mixed forms of these two types are met with.
The course of the disease is extremely prolonged, and generally fatal. Any age may
be affected. It is endemic in certain countries, where want of cleanliness and hygienic
principles lead to the transmission of the disease from person to person.

Treatment. — Choulmougra oil, 200 to 300 minims in capsules per diem, has cer-
tainly arrested the progress in some cases when given in gradually increasing doses. ^
Hypodermics of the same remedy or of mercury have controlled the disease in certain
cases, and recently the injection of nastin 10 c.c, once a week, has given good
results.

VL Erjthema Indniatiun Scrofoloiomm (Bazin's Disease) is a rare tuberculous
condition, affecting chiefly young strumous women, and characterised by chronic
subcutaneous nodules in the calves of the legs, which may ulcerate. They are some-
times difficult to distinguish from syphilitic gummata, but the latter are much more
rapid in their progress, and yield to iodides. A spurious form of Bazin^s disease is
met with in young persons who have a feeble circulation. This leads to hypostasis of
the legs, the skin of which is apt to be thickened and livid at certain spots, but the
subcutaneous nodules of Bazin's disease are wanting.

VII. MoUnicnm Ck>ntagiosam consists of roimded, pearl-like elevations, varying
in size from a pin's head to a pea, and somi-translucent appearance. A tiny depres-
sion is found in the centre through which the contents can be squeezed. If left alone
inflammation and suppuration may occur, with spontaneous cure. The treatment
consists either in snipping them off, or in squeezing out the contents, and touching the
bases with silver nitrate or iodine.

VIII. MoUmcam Fibrosum is a rare condition which consists in the formation of
.fibrous tissue in the deeper layers of the corium, slowly developing into tumours of
varying size (up to 32 pounds), which may be sessile or pedunculated. Their favourit«
situation is the back. They should be removed by knife or ligature. One case under
my care improved by painting with ethylate of sodium.

^ Kaposi, '' Diseases of the iSkin,'' l89o.

' See a case recorded by the author, din. Soc. Trans., about 1896.

§ 492 ] RARER FORMS OF NODULAR ERUPTIONS 677

IX. Sarcoma Cutis may ooour either as a primary affection or secondary to deposits
elsewhere. It is met with in the form of purplish tumours of varying size of hard
or spongy oonsistenoe. A small deposit with satellites around it is very characteristic.
Sarcoma may develop on pigmented moles, a melanotic sarcoma being then reproduced
elsewhere.

X. Actinomycosis is a rare chronic affection of the subcutaneous tissue, usually
starting in the jaw, and spreading thence to the skin of the face and neck. It is due
to the ray fungus or Actinomyces, which gives rise to a hard, slow-growing tumour,
going on to ulceration, with a thin sero-purulent discharge, containing ydUno granvlea
in which the ray fungus can he found (§ 627). In other oases the disease attacks the
lungs, the digestive tract, or the liver, causing much constitutional disturbance. The
fung^ enters through eating diseased grain improperly cooked. The prognosis is
favourable if the disease is on the surface, where it can be dealt with surgically, or if
taken early, when large doses of pot. iod. control the growth.

XI. In LeokflBmia and in lymphadenoma there are in a few cases nodules in the skin
of the same character as those in the spleen, liver, etc. These vary in colour from
that of the surrounding skin to a deep red or even to a distinct grey. They are not
infrequently the site of haemorrhages, when the colour is modified accordingly. The
greenish hue of an old bruise may give rise to the suggestion that they are chloro-
matous. but this is seldom the case. They may appear in any position, and are very
variable in size and persistence, sometimes disappearing altogether for months at a
time. If a blood examination is not mckde, such cases are often regarded as examples
of mycosis fungoides.

XII. Frambcsiia or Taws is a chronic disease endemic in the tropics, rarely attacking
the whito population. The commonest form of eruption has a fungoid or raspberry-
like character, whence its name is derived. Some observers consider the disease as
identical with syphilis, modified by the climate, but it has been successfully inoculated
into syphilitic patients.

Xin. Mycosis Fungoides is a rare condition, characterised by the formation, after
a long preliminary period, of reddish fungoid tumours. In the preliminary stages,
which may last for months or years, there is an erythema or a scaly eczema attended
by itching, followed by brownish-red papules, which leave pigmented and atrophied
depressions, and are finally followed by smooth purple tumours, sessile or pedunculated,
which ulcerate, with a typical granulomatous base. The eruption usually appears on
the trunk, and leads to emaciation and death. X rays have proved useful.

XIV. Blastomycosis is an extremely rare disease affecting chiefly the face and
hands, characterised by papillomatous ulceration simulating tuberculosis cutis, and
due to the fungus blastomyoes. It may attack the viscera primarily or secondarily.
Iodides and X rays are useful.

Xy. Sporotrichosis is a rare disease due to the presence of sporotrichia, which
apparently reach the skin through small abrasions. Inflammatory nodules occur on
skin and mucous membranes, in subcutaneous tissue and bones. Some ulcerate and
discharge a sticky pus in which the organism can be discovered. It may cause
difficulty in diagnosis owing to its clinical resemblances to tuberculosis, syphilis,
Bazin's disease or boils. The discs se yields to treatment with iodides.

XVI. Madura Foot is a granulomatous condition due to streptothrix and other infec-
tion. It attacks the foot, appearing first as nodules with bullsa, which break down,
exuding granular masses. The whole foot becomes swollen, the leg above atrophies.
Surgical intervention is necessary. The disease occurs in India, Africa, and America

GROUP VL ULCERATIONS.

§402. An uloer is a loss of substance of the dermis and epidermis
exposing a granular surface, which secretes a sero-purulent fluid. Ulcers
must not be confused with large vesicular or bullous lesions, such as occur
in pemphigus foliaceus, m which the skin is only denuded of it^ cuticle.
For clinical purposes idcers may be divided into four groups :

•78 THE SKIN [ § 482

(a) Id4oj)aihic or inflammatory ulcers, caused by injury, hypostatic con-
gestion, or varicose veins, and often aggravated by some blood dyscrasia,
such a^ gout, anaemia, or scurvy.

In the Treatment of chronic ulcers the main point to remember is t)ieir absence of
tendency to repcur. (1) Many local applicationa have been tried. If the discharge is
watery and excessive, and the granulations turgid, astringents are called for, such as
zinc sulphate or lead lotion, or the painting on of nitrate of silver, 20 grains to the
ounce, or the use of the solid stick, which acts also as an excellent stimulant. For the
troublesome itching, carbolic lotion, 1 in 50. or 1 in 100. freely applied on lint or rag.
often gives relief. Meat extracts and oxygen have been used as applications, and
various protective dressings, such as strapping and starch dressings, are often success-
ful. (2) Best in the horizontal position is more efficacious than any other kind of
treatment for ulcer of the leg. because the deficient return of the blood is one of the
factors which prevent repair. With the same object a Martin's rubber bandage, a
flannel roller, an elastic stocking, or a Scott's dressing is advantageous. (3) A liberal
diet, and a moderate use of stimulants are often successful, combined with tonics, and
among the internal remedies which I have found successful with aged persons is
tr. opii, 2 to 6 minims, thrice daily. It acts by improving the tone of the cutaneous
vessels. It may be combined with strychnine, which is one of the best tonics for the
aged with which I am acquainted. (4) Incisions may be made through callous,
indolent odges, either at right angles or parallel, to release the adhesions between them
and the deep parts. Grafting by Thiersch's or some other method is, however, more
snooeflBfol.

(6) The coniagiaus ulcere are hard chancre, soft chancre, the ulcer at the seat of
inoculation of glanders, and certain tropical ulcers due to the poisonous stings of
certain insects, and the inoculation of certain tropical diseases.

(e) Neuropathic ulcere — e,g,, perforating ulcer in tabes dorsalis.

(d) InfiUraHng or neopUuiic ulcere are due to the breaking down of some infiltration
which has invaded the skin or subcutaneous tissue, and which can be detected in the
tissue around — such as syphilis (rupial ulceration and breaking down of a gumma),
lupus vulgaris, tuberculosis of the glands breaking down (strumous ulceration),
epithelioma, rodent ulcer, leprosy, Bazin's disease, sporotrichosis, and other nodular
conditions.

The differentiation of these several varieties depends largely on the histoiy, ihe
associated symptoms, the distribution and character of the ulcers, and these have
been given under their respective titles.

An infiltrating, ulcerating, and scarring eruption in a pereon of young or
middle age is practically either syphilis, lupus, or tuberculous ulceration.
If it occurs over forty or forty- five, epithelioma and rodent ulcer enter Ae
category.

I. Syphilitic TJlooration — other than the primary chancre — ^is of two
kinds : (1) The breaking down of a large papular or lenticular syphilide
in the skin gives rise to shallow irregular ulceration which may be covered
with a scab which resembles the layers of an oyster shell (m^a of older
authors). (2) The breaking down of a gummatous nodule which has
started beneath the skin produces a deep punched-out ulcer. The three
characteristic signs about all syphilitic ulcerations are — (1) the peripheral
ring of infiltration, (2) the ptmched-out edge, and (3) the comparatively
rapid march. The diagnosis from lupus and rodent ulceration is given in
tabular form on p. 679.

II. Lupiit Vnlgarif may ulcerate, but only when near a mucous orifice, or subjected
to injury and secondary infection. The nodules around are sufficiently characteristic
(J 490).

GROUP Vl.—VLCBRS
Table ov Diaqhobis.

OROUP TJI. WABTS AND EKORBaOESOBS.

S 498. Thia group, vhioh does not inolude neoplastic fonnatioas
referred to in the last two groups, consists of veiruca (wait), oondyloma,
corns, rupia, keratoderinia, papilloma lineare, acanthosis nigricans, poro-
keratosis, and angiokeratoma.

Vemoa, wart, or papilloma cutis. Is an excrescence consisting of thick-
ened epidermis containing elongated papillse. Warta may occur singly, or
they may be multiple. They are most frequently met with, on the hands.
More rarely they occur on the head, face, or genital organs. The Oauw

Fig. IM.— TttBDO* lIMSMRnO& oa tha huid ol a guneketper, aged UiIrt;-aTa.

of warts is obscure, but they are undoubtedly in some cases contagions
{Dr. J. F. Payne), and in that way spread over the hands and other parts
of the body.

VariOMt. — I. V. vulgaris occurs on the hands, and forma a homy growth
the size of a small pea. 2. F. plana, a flat, dark brown elevation found on
the face or back of old people. 3. V. aouminaia is moist, sessile, or pedun-
culated, usually quite small, but may grow to be as large as the flst, occurs
chieSy on the genital organs, oi where opposed surfaces are in contact, and
resembles condylomata. 4. V. seborrhceioa is an oily, fawn-coloured,
slightly elevated and rounded body, in which the papillte are mixed with
inspissated sebum. F. necrogenica, or " poat-mortem wart," is a tuber-
culous infection of the skin which appears on the hands of doctors, post-
mortem porters, leather-dressers, cooks, butehers, etc. It starts as a crimson.

§494] GROUP VII.^WARTY ERUPTIONS 681

flat, indurated papule, which spreads, and somethneB becomes pustular, the
pus drjdng and forming into a scab. A white and pinkish stellate cicatrix
maj be left behind as the disease progresses (Pig. 134). Warts -are best
dealt with by applications of glacial acetic acid, potassa fusa, or other
caustics, or salicylic acid plaster. Small doses of mag. sulph. t.i.d. have
cured some cases. X rays and carbonic acid snow are used in obstinate
cases. F. necrogenica is treated like lupus.

Syphilitic Condyloma is really a papular syphilide occurring (1) on the
mucous membranes ; (2) near the junction of mucous membrane and skin ;
or (3) where opposed skin surfaces are in contact. They very commonly
occur at the angles of the mouth, and between the buttocks or labi^.*
They are slightly raised discs of various sizes, covered with greyish epithelial
or soddened epidermal flakes, and exuding a highly contagious fluid.

Oomf are localised thiokenings of the epidermis consequent on localised pressure.
The side of the toe is a common position. They may be cured by painting with salioylio
acid (20 per cent. ) and collodion every night for a week ; soon afterwards the com will
flake off. Soft corns arise between the toes, due to hard corns becoming soddened
with perspiration. Treatment consists in keeping them dry with dusting powder,
such as zinc oxide and starch, keeping the toes separate with small pads of cotton wool,
and by relieving pressure.

PapUloma Lineare has been described under Ichthyosis. $ 476.

KeratodermU may occur in (i.) syphilis. In the tertiary stages it appears as a very
thickened brownish hyperkeratosis of the sole of the foot, usually associated with the
thickening of the whole leg. It may also occur in the secondary stage, which is
bilateral and not usually so marked in degree, (ii.) Gonorrhoea, when accompanied
by severe constitutional symptoms, has in a few cases been associated with a sym-
metrical homy eruption on the soles of the feet. Under the homy covering are dark
sloe-like nodules, (iii.) Keratodermia palmaris and palmaris (tylosis) is a family
and hereditary hyperkeratosis which may have marked homy excrescences on palms
and soles. In debilitated subjects secondary ayphilitic lesions may ulcerate, with a
dried bloodstained crust, which is compared to a limpet shell, and is known as Biipia.
Similar high crusts may occur in psoriasis, but these have no underlying ulcer.

Aoanthotii Nigrioani is a rare condition characterised by progressive pigmentation
of the skin, with papillary growths, terminating fatally in a few years. The colour of
the skin varies from a scdlow hue to bronze and dirty brown. It is generalised, but
more pronounced in the flexures. The disease may occur at any age after childhood.
In most of the recorded oases it has been associated with abdominal cancer, but. in
others no cause has been found.

Porokeratoeif » a very rare disease, occurring chiefly on the backs of the hands and
on the feet, is characterised by patches of atrophic skin, surrounded by a thin homy
ridge or " wall ** immediately inside which are seen tiny grey papules, which can be
picked out. It is said to be a hyperkeratosis of the mouths of the sweat glands with
destruction of glands and hair follicles. It starts in childhood and progresses
slowly.

Angiokeratoma is a rare condition consisting of telangiectases, which develop into
warty growths, occurring usually after chilblains, on the backs of the fingers, toes,
hands, and feet. Treatment consists in emplo3mig warmth and electrolysis.

OROUP VIIL ATROPHIES AND SOARS,

§494. Scars, scleroderma, and atrophy of the skin may be considered
together, because they not only resemble each other clinically, but fibrosis
of some of the cutaneous tissues and atrophy of others occurs in varying
degrees in all three conditions. The disorders met with in this group are :

0S2 THE SKIN I i 4M

I. Sdars. 11. Atrophoderma. III. Sclerodenna. IV. Keloid and its
congeners Rhinosoleroma, "Kraurosis VuIvaB, and Ainhnm.

I. Scan may result from bums, wounds, or infiltrating or suppurating eruptions in
which there has been a loss of substance. If much deformity or loss of mobility
results, plastic operations are called for ; but it is wonderful how much can be done
in young patients by means of persevering massage with oleaginous substances, and
Specially, in my experience, cod-liver oil. Soars are liable occasionally to be aff^tod
by keloid (see below).

n. Atrophoderma (Atrophy of the Skin) occura as : (a) Atrophy of the entire
cutaneous covering is common in old age ; (b) Linss albicantes is a term applied to
the atrophic streaks found on the abdomen and breasts after pregnancy, over the
hips and other parts when the patient has been getting rapidly stouter. A oaee of
linear atrophoderma due to neuritis after enteric fever is recorded by Sir Dyoe Duck-
worth.^ The author and others have also observed oases which could be traced to a
neuropathic cause, (c) Unilateral atrophy of the skin is met with in the condition
known as Hemiatrophy Facialis (| 617), which is of nerve origin.

nL floleroderma, or fibrous thickening of the skin, is met with in three clinical
forms, all of which are more or less rare : (a) Localised (or morphcaa) ; (b) diffuse ;
(c) S. neonatorum.

(a) LooALisBD ScLBRODERBfA (Synouyms : Morphoea of Erasmus Wilson, Addison's
Keloid) is a disease consisting of one or more localised ivory patches of sclerosed skin
with, in the earlier stages, a congested lilac border. The patch may be atrophic and
pigmented. There are few or no subjective sensations, but the tactile sensation is-
diminished. Some cases undergo spontaneous resolution in course of years. The
iavourite situations are the face, neck, and beneath the breast. There is a tendency
to symmetry. It is thought that the shape and distribution of some patches corre-
sponds with the distribution of a nerve, the supra-orbital being a common site, but
it seems more probable to the author that the lesions are associated in some way with
Head's sensory and visceral areas. Females are more prone to be affected in the
proportion of three to one, and the disease appears mostly in the first half of life.
Beyond the disfigurement and contraction the patient suffers but little inoonvenience
from this variety of the malady.

(6) Diffuse Solbbodbrma is a somewhat different affection to the foregoing,
and consists of a parchment-like thickening and contraction of the skin. When it
starts and predominates in the extremities, it is called sclerodactyly. It progressively
increases until the parts become completely hidebound and immobile. The Uloo in
such cases wears a smooth, expressionless aspect. This disease is one of much gravity.
By degrees fissures and ulcers form, and some of the fingers may become gangrenous,
and death from some intercurrent malady occurs. Many degrees of severity are met
with, and in some the condition only produces a constant liability to oold and to
various superadded nkin lesions.

(c) ScLBBODBBHA (Synonym : Sclerema) Nbonatobum is a different disease. It
appears oongenitally, and is generally fatal in the course of a few weeks. The affected
skin is bound down to the parts beneath in livid, tense, shining patches, which tend
to become universal.

The Treatment of the three conditions is not satisfactory. Local massage may be
recommended. Several slighter degrees of generalised scleroderma under my care
improved under thyroid. . !nie constant current, hot air and light baths, and fibrolysin
have done good in the localised form. Electrolysis does good in morphcea.

IV. Keloid consists of a fibromatous deposit in the skin occurring primarily in un-
affiected skin, or secondly in old cicatrices. The lesion appears as a small firm nodule,
of a crimson or pinkish colour, which slowly enlarges by means of tentacle-like pro-
cesses. At first it is raised above the skin level. Such growths if excised immediately
recur, and in that sense are malignant. The negative pole of a mild constant current
has been attended with favourable results. Fibrolysin injections and X rays are
useful.

^ Brit. Joum, Dermat,, No. 62, vol. v.

i4M] PIGMENTARY AND VASCULAR ALTERATIONS 833

Aone Keloid (Synonyms : Dennatitis Papillaris Capillitii, Sycosis Capillitii) is a rare
disease which occurs on the nape of the neck, a slow pustular affection, resulting in
keloid formation.

Rhinofoleroma is a chronic inflammatory affection characterised by the develop-
ment of hard, circumscribed, nodular growths in the skin and mucous membrane,
moflt commonly of the nose and naso-pharynz. due, it is believed, to inoculation with
a apeoiiio bacillus. The bones and cartilage may be involved.

Kranrofis Valv« is an atrophy and contraction of the mucous membrane of the
external genitals and adjacent perineum of women. The tissues are atrophied with
thickened patches.

Leukoplakia Valv» is a chronic itchy inflammation of the vulva, wiUi a stage of
hypertrophy, followed by stages of leukoplakia, cracks and fissures, with subsequent
atrophy and sclerosis.

Ainhpm consists of a slow strangulation and amputation of one or more toes by
the growth of a constricting band of hypertrophied skin. It is not seen in this
country.

QROVP IX. PIGMENTARY AND VASCULAR ALTERATIONS,

§ 496. Alterations of colour depend mainly upon the condition of the
vessels and the amount of pigment in the skin. A diminution of pigment
is not frequent, and occurs only in two conditions : (1) Albinism, a con-
genital condition in which there is deficient pigment in the skin and its
appendages, and in the iris and choroid ; and (2) Leucoderma (Synonym :
Vitiligo), a condition in which there is an absence of normal pigment in
areas which are surrounded by darker-coloured skin. The transition
from the pale to the dark area is abrupt, and it is the dark-coloured margins
which attract the notice of the patient. It may be congenital or acquired,
and is probably neurotrophic in its origin.

a. A localiaed increase of pigment or alteration in colour occurs in :

I. Chloasma.
II. Lentigo.

III. Pityriasis versicolor.

IV. Pigmentary and vascular moles.
V. Purpura.

VI. Urticaria pigmentosa.

VII. Xeroderma pigmentosa.

VIII. Xanthoma.

IX. Morphoea alba and nigra.

X. Ochronosis.

XI. Leprosy.

b. A generaiised increase of pigment occurs in (1) arsenical and silver pigmenta-
tion ; (2) Addison's disease ; (3) abdominal cancer ; (4) oardio-vascular disease ;
(5) bronzed diabetes; (6) constipation ; (7) melanotic sarcoma; and (8) acanthosis
nigricans ; but in these the pigmentation is subordinate to other symptoms.

I. Obloaima occurs in single or multiple patches of diffuse discoloration on various
parte of the body, var3ing in shade from a light yellow to a deep brown. Several
varieties may be referred to : 1. Chloasma m/mptomatica is met with most frequently
in pregnancy or uterine disease, and its most usual position is on the face and round the
nipples. 2. Chloasma caehecticorum occurs in association with malaria, cancer, senile
atrophy, rheumatoid arthritis, abdominal tubercle, or cancer, and exophthalmic
goitre. 3. Chloasma traumatica is the pigmentation beneath the garters, or around
the waist in tight-laoing women, in pediculosis or scratching, and after sinapisms,
blisters, etc. In this category may be included the pigmentation which follows
chronic eczema, syphilis, lichen planus, psoriasis, or any other long-oontinued afflux

BM THE SKIS [ j 4M

in the skin oftpMIaries. 4. Ohloatma ealorieum is the pigmentation due to lan Mid
wind, or to beat, aa on the ahina of women who rit over the Gre. It ftleo foUowa
exposure to X rays.

n. Ltntlgo (SjnoDymB; Freckles. Ephelides).— Freokles are multiple, oinnim-
■oribed pigment spots on tlie portioiu of tbe body exposed to light. In advanced
age they may oocnr anywherR, and are apt to tieoome malignant by taking on an
epitheliomatouB growth.

m. TinM Tutlooloi (Synonym : Pityriasis Venioolor) ia a vegetable paraaitir
affection of the skin, which appears as variously siied, irregularly shaped, dry. highly
furfuraoeouB patches, yellowish -brown in colour, fonnd geneniUy upon the trnnk.
and especUUy in the hollow
of the breast bone, due to a
speciGo parasitio fungus, the
mioroBporon furfur (Fig. 136).
IV. Pifmented ud TtMuUr
Hoisi are distinguished from
other pigmented conditions by
their being congenital, and
being mote or less raised.
NnvoB spilua is a smooth
discoloured spot of otherwise
healthy skin. Nnvns verru-
cosus is rough, and sometimes
bristling with hairs (navus
piloBUs). Vaicvlar mciu an-
purple spots of increased vas-
cularity, usuaUy a little raist-il
above the surface, varying
widely in size and thickness.
They are sometimes stationary,
but more often gndually in-
crease in size. Tdangitfla*u is

„ .„ „ ^ .. a localised dilatation of the

Fig- !».— MioaoeromoN FtrRnrs, the tangiu at Phtkiabis „„„i. „f ,i,„ .ti„ ,„h i. > fn-

VUSIOOLOB, xabout 60.— 8how« the braachlna Inwa- ™"«" <" '"» """*■ ""* " " "^^

Isr mymilum and the caDit«tlations el tporsi. Stained quent accompamment of acno

by Oram's method. rosaoea. Small spots are met

with independently of any skin

affection on the face and various parts of the body in healthy persons, particularly u

life advances, or when tbe peripheral oiroulation is feeble. Port-wine mark is a venous

and capillary dilatation over an area of skin.

TTtatment. — Leucodorma, lentigo, and chloasma aie best treated with strong mor-
curial lotions (i to I per cent.), but they are difficnlt to eure. For pityriaais versi-
color thorough oieansing with a bard brash and soap is the essential treatment,
together with ung. aulph. or a lotion of aod. hyposnlph. (1 draohm to the ounce).
Electrolysis, esoharotioa. or excision give good results in pigmented and vascular
nnvi ; for the hitter carbon dioxide snow is now widely employed.'

{ 4H. 7. Poipont consists of dark, abrupt-edged purple spots due to extravasa-
tions of blood into tbe skin. The eruption does not fade on pressure. It is Borne-
times accompanied by similar extravasatioos into the mncons membranes and in-
ternal organs, and hiemorrhages from tbe mucous siu&oes. The oonstitatjoiud
symptoms vary considerably, and may be absent. Pyrexia, usually alight, occurs in
about half the oases.

Tbe Oatua of purpura are but little understood, but may be grouped onder three
headings : I. Local and tnechanicai causes, such as htart duttue and old agt. Tbe most
frequent illustration of this is met with in eczema of the leg (indeed, most eruptions
on tbe legs of old people), which assunies a purpuric character on acoount of the
hypostasis of the blood. Mitral disease is associated not infrequently with pntpurio
eruptions on the legs. 2. Purpura is associated with oertAia nemout conditions, eooh

> Beginald Morton, Brit. Med. Assoc Meeting, 1910.

{496] PURPURA 686

as oerebro-spiual meningitis, tabes, myelitis, hysteria, and, according to some,
neuralgia. 3. Changes in the blood produce purpura in (i.) various fevers, especially
typhus (typhus has been called purpura contagiosa) pneumonia and cerebro-spinal
fever, in which a purpuric eruption is frequent ; measles sometimes ; malignant endo-
carditis, and pyemia occasionally ; the initial stages of small-poz, and in the malignant
type of that and most of the other acute specific fevers ; (ii.) certain drugs occasionally,
especially mercury and iodide, quinine, copaiba, belladonna, ergot, salicylic acid, and
the mineral salte ; (iii.) autotoxic conditions, such as Bright's disease, hepatic disease,
including cirrhosis, acute atrophy, carcinoma, and any aggravated jaundice ; bad food
also seems in some cases to account for the onset of purpura ; and (iv.) constitutional
diseases, such as leuksemia, scurvy, lymphadenoma, and great debility from any cause.

Four special varieties of purpura are recognised, (a) Purpura Simplex (morbus
maculoBUs of Werlhof) is the name given to a mild attack of purpura for which no
cause can be assigned. It is usually met with in young persons, and runs a benign
course, (b) P. Hcsmorrhagica is a severer variety, which may start as P. Simplex,
or independently. The spots are larger, and sometimes raised or oedemato us. Hsemor-
rhage occurs from the mucous membranes, and pyrexia is more marked, (c) P. Rheu-
matica (Peliosis Rheumatica, Schonlein's disease), and Henoch's Purpura, described
in § 435. {d) Purpura and erythema are related, the first being due to an exudation
of ail the constituents of the blood, the second to an exudation of serum. Conse-
quently it is not surprising to find that many intervening stages of the two are met
with, and are known as purpuric erythema.

The Diagnosis of purpura' is easy, but difficulty lies in ascertaining its cause. The
diagnosis from scurvy has been given (§ 410). Consider the previous history, and
thoroughly examine every organ and the blood. In hcBmophUia the blood clots slowly
and the clot contracts : in purpura the clot does not contract. {B.M.J., March 30, 1912. )

The Prognosis is extremely grave when associated with the specific fevers, or with
a high temperature. P. simplex usually results in recovery in a few weeks ; p. rheu-
matica is rarely fatal, though it may last for months or years, and may recur ; Henoch's
purpura is favourable as regards recovery, but is apt to recur.

The Treatment is unsatisfiactory ; arsenic, iron, ergot, and ol. terebinth deserve trial.
Calcium chloride and adrenalin are useful.

VI. Urtioaria Pigmentosa (described by Nettleship in 1869, and so named sttbse-
quently by Sangster) is a chronic or recurrent urticaria, in which each crop of wheals
leaves behind spots of brown pigmentation of considerable persistency. The disease
starts in early childhood ; it may cease spontaneously about puberty, but it more
frequently lasts for many years. The Treatment is like that of urticaria, plus calcium
chloride and bromides.

VU. Xeroderma Pigmentofs (Sjmonym : Kaposi's Disease) is a rare disease of a
chronic progressive character starting in early childhood, often in members of the same
family, and marked by small dark freckles, with atrophy and contraction of the skin
between them, and the occurrence of telangiectases. There is also a distinct tendency
to a malignant new growth, both in the skin and the internal organs in the shape
of a malignant sarcomatous or cancerous infiltration. The distribution is universal,
and the contraction gives rise to eversion of the eyelids and other orifices. It usually
terminates in death before the age of twenty -two.

VIU. Xanthoma (Sjmonym : Xanthelasma) is a rare condition most commonly
occurring in the face in cases of diabetes and chronic jaundice. It consists of yellowish
nodular deposits in and beneath the cutis, varying in size from a millet-seed to a
bean, or larger.

IX. Iforphcsa Nigra and Morphcsa Alba are names employed by Erasmus Wilson
for the disease which we now describe as localised scleroderma (§ 494), when attended
by excess or deficiency of pigment.

X. Ochronoiii is a rare disease characterised by blackening of the cartilages and
ligaments and fibrous tissue beneath the skin. The sclerotics and extensive areas of
the skin may show black pigmented patches. There is sometimes arthritis, and alkap-
tonuria (§ 287) is always associated.

XI. Leprosy (§ 491). — Patches of pigment and white spots may occur in the early
stage of anaesthetic leprosy, and dark spots occur, especially on the face, in the early
stage of nodular leprosy.

686 THE SKIN [ K 487» 498

GEOUP X. DISORDERS OF THE SWEAT.

§ 497. Four disordere of sweat are met with : Anidrosis, hyperidroBis* bromidrosis,
a&d ohromidroais.

I. Anidrorii is not oommon apart from the oonditions mentioned in Group VUL

II. Hypecidrofis is the term applied to an excessive secretion of the perspiration,
and may be general or localised. When general it may be due to a lowered neuro*
vascular tone, excitement, corpulency, or the use of stimulating foods and drinks.
It also occurs in fevers at the crisis, in ague, acute rheumatism, chronio tubetonlosis.
The localised form affects most often the feet, axillsB, and palms. The sweat mixed
with sebaceous secretion decomposes on the clothing, and gives rise to a pungent and
disagrreeable odour. The feet are apt to become tender, and eczema may supervene.

The TreatmerU of hyperidrosis consists of the application locally of a mixture of
tr. belladonna and water equal parte, or sponging with vinegar aud water ; and inter-
nally hypodermics of atropin, or the administration of arsenic and the mineral acids
or tonics. Local hyperidrosis, especially of the feet, is troublesome to get rid of.
The stockings shotdd be changed several times a day, and put into a saturated solution
of boracic acid before being used again. Dusting powders relieve tha slighter forms.
Applications of tannic acid, chromic acid, salicylic acid, and of diachylon plaster
should be tried in graver cases. In severe hyperidrosis of the axUlse I have had
good results with X rays (A. F. S.).

m. Bromidroiif is the term applied to a disturbance in the function of the sweat
glands in which the perspiration bias an offensive odour. Mere excess of persforation
in the feet or axillsa may render the person disagreeable to his companions. The
subject is therefore interwoven with hyperidrosis. to which reference should be made
for the treatment.

IV. Ohromidrofii is a rare disturbance in the function of the sweat glands in which
the perspiration is coloured.

OROUP XL DISEASES OF THE SCALP AND HAIR.

i 198. The diseases special to the scalp and hair are :

I. Ringworm. VII. Hirsuties.

II. Favus. VIII. Trichoptylosis.

III. Alopecia. ^ IX. Trichorrexis Nodosa.

IV. Pityriasis and Seborrhosa. i X. Leptothrix.

V. Canities. XI. Tinea Imbricata.

VI. Pediculi Capitis.

I. Riligwonn (Synonyms : Trichophytosis Capitis, Tinea Tonsurans)
may be caused by the small spored fungus, microsporon Audouini, and
by the large spored fungi, the Trichophytons endothrix and eoto-endothrix
(see Figs. 136 and 137). The clinical appearance varies with the form of
infection. About 90 per cent, of the cases occurring in England are due
to the microsporon, but this variety is somewhat rare abroad. It starts
as an insignificant, semi-bald, pink patch, usually overlooked, and when
first seen by the physician is a white, powdery, circular patch on the scalp
of children, with broken hairs. The spot varies from the size of a three-
penny piece to one denuding half the scalp. Kerion may occur ; it is a
condition in which there is a boggy suppurating patch on the head. In
the variety due to the endothrix there may be few or no scales on the patch ;
broken hairs are found at its margin, and on the patch itself, which may be
quite bald, there are often black dots due to the hairs being broken ofi
level with the scalp. When the ecto- endothrix affects the scalp, kerion is
common. This fungus is of animal origin.

i «8 ] GROUP Xl.—DISEASES Of TUB SCALF 687

Diagnont. — The broken hair stumps are quite ohaiaotemtic. Dabbing
chloroform over the part will reveal the diseased haire, which then look
whitened like hoar &ost. The diagnosis should be clinched b; placing
the hair on a slide with a drop of liquor potassee, and examining under the
microscope. The varieties of the fungus, however, can only be distin-
guished after staining by Gram's method (g C2T), and by their culture
characteristics. A bald form of ringworm occasionally occurs resembling
alopecia areata, but some broken stumps of hairs can be found at the margins
of the patches.

Etiology. — The disease is rare in children over fourteen, but common
under ten. Fair-haired children are more susceptible. Adults are prac-
tically immune. Animals, especially domestic animals, may contract
ringworm and give it to children. The disease spreads rapidly in families
and schools, and is due to a specific fungus.

WOBH [HIcnHporon AadanlolJ
under a J -inch objrcCivii. —
Spores rormlDg ■ thlcb-iet

Prognons. — The disease lasts an indefbite time, but tends to disappear
spontaneously about puberty. Much depends upon the stage at which
the disease is first seen, the diligence of the treatment, and the variety of
spore present, the small spore being much more intractable, Fair-haired
children are more difficult to cuie. The average duration is two or three
years. Varietie) with kerion usually run a shorter course.

TreaJmen^. ^Ringworm is a most difficult malady to cure, and great
perseverance is required. The head should be shaved every ten days,
and a linen cap worn which can be renewed every two or three days, the
old one being burned. Patches seen very early may be aborted with
strong parasiticides — e.g. pure carbolic acid, iodine, or croton-oil. Every
day (1) cleanse and remove alt debris with A.C.E. mixture; (2) apply
parasiticides. Air and water should, as far as possible, be excluded.
Amongst the numerous remedies may be mentioned salicylic acid (10 grains
to the ounce of collodion), chrysarobin, carbolic, mercury, and oil of cade
in varying strengths ; and it is well to change the remedies at times. It

S88 THE BKiy [ 1 4M

IB often very difficult tu decide wheu a child in free from infect-ion. My own
method \a to leave the case which appears cured without treatment and
untoufthed for ten days. If at the end of that time the surface is free from
Bcaliness, the hairs are growing normally, and the mioroscope gives negative
results, I recommend further treatment for a week, and then, after a
second interval of ten days, if the same testa answer, I pronounce the case
as probably cured. When the services of a dermatologist skilled in the
use of the X rays can be obtained, the quickest and best method of curing
rin^orm is to epilate the hair by the Sabouraud method of X-ray ad-
ministration.

LI. fanu oooDia on the head oad the body. It U rare in Eoghuid, bat oommoiLer in
Hootland. It formi tuoh otiknotvriBtic irregular jellow aruata. itith yellow, oop-
•hkped tops, and is aoooiiip»iiied by euoh a mousy smell, that the diagnoaie U not
difficult. The miorosoope Tereals the apore* and the
mycelium of the aclionon Schonleinii (Pig. 138). It
develops slowly, is luioompaiued by itehing, and
leaves atrophic scan. It is leas ooatagioaa than
rinK<TOnn. but more intractable. It may spread to
the body. The treatmeQt is the same aa in that
diseuc, but epiUtion is more necewary.

III. Alopecia (Baldness) may be congenital

or acquired, partial or complete, diffuse or

in patches. The acquired condition may arise

from (I) jiremature senUUy, which usually

begins on the vertex ; (2) general malntttn-

m. i3«-FivcB FcKutPs <tlDca '*^' ^^''° ^^^ ^a.\iiM is diffuse, as in tuber-

fkvoH or uhDiioD sciianlelnii) culosis, acute fevers, ancemia, and nervous

STiSSu'-iESi l^r^iitZ exhaustion ; (a) sypAi/w, in which the bald-

iwcSliLS'd'tXS"'" '^^^ '^ disHeminated or patchy in the early

stages, or localised in the later stages of the

disease (being then due to syphilitic lesions of tlie skin) ; (4) favm

and ringworm, which a&ect the hairs and lead usually only to temporary

and localised baldness ; (5) Iujms erylhemalosua, in which the bald patches

are permanent; (6) impetigo, eczema, X rays, etc., with temporary loss

of hair ; (7) leborrhcBO capitU, which is probably the commonest cause of

baldness in meu ; (8) pityriasis capitis, a common cause, especially in

women ; (9) two forms of cicatricial alopecia are met with rarely — pseudo-

pelade of Brocq, and folliculitis deoalvana.

Akqiwia Axsata b a special form of baldness occurring in circular
patches which are smooth and white. Each patch slowly increases peri-
pherally, and at the margin short diseased hairs may be seen, which have
so oharacteristio an appearance as to enable us at once to identify the
disease. The free end is of normal thickness, but presents a ragged
fracture where the hair has been broken off ; from this point the shaft
gradually becomes thinner towards the root, which is extremely atrophied.
Thus it somewhat resembles a note of exclamation (!). Any part of the
body may be affected. The disease runs a very protracted conrse, lasting,
if untreated, for years. In course of time a few downy hairs begin to grow.

§ 498 ] DISEASES OF THE SO ALP^ ALOPECIA 689

white at first, but gradually becoming coloured. It is undecided whether
the disease is of parasitic or neurotic origin.

In the Treatment of baldness attend to the general health, and apply
local remedies in order to stimulate the vascularity of the part by means of
lotions or ointments, commencing with ammonia, turpentine, and can-
tharides. If seborrhoea or pityriasis is present, they must be corrected.
The treatment of the bald scars left by lupus erythematosus and other
scarring eruptions of the scalp is hopeless, for the hair-bulbs are destroyed.
In alopecia areata the patient should be assured that nothing but a pro-
longed course of treatment is necessary. Galvanism, high-frequency
currents, and massage are useful. In alopecia due to the microbacillus
of Sabouraud, a form which is associated with excessive oiliness, vaccines
may be tried.^

IV. Seborrhoea Capitis Sicca is the name usually given (wrongly) to
cases of Pityriasis Sicca (dandrufE) occurring in localised patches or
generalised over the scalp. It is due to the bottle bacillus. It may be
accompanied by a degree of inflammation due to the presence of staphy-
lococcus griseus (Sabouraud). It is diagnosed from eczema by the greater
inflammation and exudation in the latter ; and from psoriasis by the larger
number and size of scales in psoriasis. An abnormally greasy scalp is
found with seborrhoea oleosa, which is due to, or at least associated with,
the microbacillus of Sabouraud. Both pityriasis and seborrhoea oleosa
may lead to diffuse hairfall and alopecia.

The Treatment consists in washing the head once or twice a week with
equal parts of soft soap and spirits of wine, and in rubbing in every night
a lotion or ointment containing mercury, tar, or sulphur.

V. Canities, or whiteness of the hair, is, as the name implies, most
usually an evidence of advancing years, or of overwork, sudden or pro-
longed grief, defective general health, or neuralgia. The Treatment is un-
satisfactory apart from the improvement of the general health by tonics.
The head should be examined for seborrhoea, pityriasis, or any other local
disease, which, though it does not cause, may expedite the loss of colour.

VI. Pedionlotii Capitis presents the following features : (1) The pediculi (Fig. 139) ;
(2) white specks on the hairs (the eggs or " nits "), which cannot be pulled off, by
which they are distinguished from dandruff (Fig. 140) ; and (3) irritation and inflam-
mation. If the condition is untreated, there results pustulation with formation of
thiok crusts, matting of the hair, and enlargement of the occipital glands. Kill the
living parasite and also the nits. This may be done by soaking the hair with methy-
lated spirit or kerosene for one or two nights, and combing the hair thoroughly with
a small-toothed comb. Ungt. hyd. amm. may be rubbed in. The nits may be dis-
solved by washing the hair with strong vinegar.

VII. Hsrpertriohotii (Synonym : Hirsuties) is a growth of hair either abnormal in
amount or in position, and the most troublesome of these is the moustache or beard
found on the faces of some women. TreaimefiU consists of the removal either by thd
razor or electrolysis. Depilatory pastes of barium or calcium do not prevent regrowth.
The X rays are useful only when employed by skilled hands.

Vni. Tricho^lodfj or splitting of the ends of the hairs, is met with sometimes
in women. It often occurs in association with deranged general health.

1 ** Treatment of Seborrhoea." by Agnes Savill, The Practitioner, 1911.

6B0 . THE 8EIN [ j «»9

IX. TriehonexU Rodon is « veiy rare dJBBase in which a neries of aplndle-Bh»ped
swellinga appeat upon the hair, which break tranavorsely. and leave a bnuh-lite
extremity.

X. Lcptothrlz (Synonyma ; Mycoais Axillaris. TrichomycoBiB Nodosa) iB a diaeas*
affeotiag the hairs of the axills and aorotnm. The haira are dry and knotty, doe to
adherent small ooncretions, which may aSect the whole length of the hair, but not
the follicle, or may occur aa separate nodules on a hair. BacilU are found in these
concretions, and the hair may be split longitudinally {Tig, 141).

XI. Tlnta Imbrioata is a contagions duorder of the tropics due to a fnngns. Its
configuration has a watered silk appearance.

{ 4M. Otnenl Remukt on th« Tieatmoit Ol BUd DitMiS*.— There are three
principles upon which we must depend for anccess : (1) If we except mercury and
iodides in S3^hilitie and other granulomata, and perhaps arsenic in lichen planuH.
pemphigus, and dermatitis herpetiformis, there are no suoh things as specific remedies
in skin diseases. It is therefore not sufficient for purposes of treatment to diagnose
a case as eoiema, psoriasis, lupus, etc. . We must recognise tht ilngt of Ihe dUvue and
the 'prtciae pathologiral proMJi before us. An ointment which would cure a chronic
eelema would greatly aggravate an acute weeping one. It follows, therefore, that jt
depends not so much upon Hie name which we decide to give to an eruption, aa upon

Pig. ISB.— PKniODlCB Capru X 10.— It
dlScn from the pedlcnius carports
onir Id beinc shorter. bdcI In lis thorax
SDd atidomeD being more oeariy equal
In alie (see p. sag).

the amonnt of oongeation, swelling, seating, thickening, discharge, itching, el«., which
is present. We have, in a word, to treat the Bjmpfoms, the sum of which oonslitutes
the disease at that particular moment. This requires very considerable eiperieooe.
and herein lies one of the justificatjons of the speciality of dermatology. (2) The
method of application of a remedy is of quite as much importance as the composition
of it. (3) The idiotynt,Ta»y of a patient and the susceptilrility of his skin to varions
remedies must always be remembered. This a especially true of the faee, for what
will benefit one person's skin will irritate another's.

Bearing in mind these three important considerations, it may be convenient to divide
ext«mal remedies into three groups, the first being ohiefiy indicated for acute, oon-
gestive, or moist oonditions, the second tor dry, scaly, hard, and ohronio oouditjoiu.
and the third group (oanstics) having a oorrosive action for the removal of diseased

(a) Sbdaitves and AaTBtROKiiTS are used obiefly in acute oonditions to rednoe
hyperomia, to cheek exudation, and to allay pain. Enumerated in order of increasing
strength the most important are xinc, lead, bismuth, mercurous, and, in a less decree,
merouric and silver salts. Zinc and bismuth are inert on the unbroken skin. These
remedies ate generally applied in the form of ointments, aa'a powder, or, still bett«r,
BUspendod in lotiont for acute eczema and similar moist conditions.'^^Snc olea(« is also

ilM] TREATMENT OF HKIl) DISEAHES Ml

a tdknd preparation, and zino gelatjno may be used when there ii little disobargr.
Ung. diftobyli ia also soothing. Mercurial preparations are more cffioaoious in ohronic
oonditiona. Tlio perohloride is irritating, luid if uaed strong oomea under the heading
of canstioB. Vegetable astringents are not much used, though the gljcerine of buinic
aoid may be used for oocgestive oonditiona around the muooua orifioes.

(6) Sttmdlatiiiq AppucArions, AnTiBBPnoa, Tabs, and AiioBATica are (leehil to
stimulate ohronio conditions to more betiltby action. They iaolude wood tar or
creosote, and coal tar or oreolin, oarbolio ftoid, reioroin, thymol, ^'naphthol, benzoic
and salioylic acids — salioylio aoid especially being ft very useful preparation to reduoo
hyperplasia of the epidermis — Jchthyol, sulphur, and ohrysarobin. The earlier
named of these are lesa irritating than the later ones ; indeod, weak preparations of
tar may act as a sedative.

{c) CAUSTica have a definite corrosive action upon the skin. Thus liquor potassv
may be used to remove the superdaons epidermal scales of psDrituis prior to the

Fig. 141. — LirroTHRii, lUghtEy mieolfled.

application of an ointment or plaster. Others are mercuric chloride, aoid nitrate of
mercury, nitrio oeid, pure oarbolio acid, etc. Soft soap is the mildest of such prepara-
tions, and may be usefully added to aa ointment for the treatment of inveterate
psoriasis.

(d) pEOTBcnvB MB43UBK3.— The old-fashioned paste— i.e., an ointment made up
with a large proportion of some powder [e.g.. F. 76) — cornea under this heading.
Pastes ore applied by laying on in a thiek layer. One of the most useful forms of
proteetion la zrsc oei^tikb. Painted on to the diseased skin this fulfils four indica-
tions : (i.) Qentle oompression and support, as in varicose eczema or hypostatic con-
gestion ; (ii.) protection from the action of the air or friction while allowing natural
evaporation and healthy action to go on beneath ; (iii.) it allays itching ; (iv.) is an
escoUent dressing and means of applying remedial agents constantly. Another
protective agent is the plaster huu. introduced by Unna (Hamburg), which oonsista
of reagents mixed with gutta-percha and some basis, and spread upon a piece of muslin.

CHAPTER XIX

THE NERVOUS SYSTEM

The nervous system is the governing and controlling power of the body,
and permeates every other system and structure. As a consequence the
investigation of its diseases necessarily requires a wide knowledge, and it
also presents a certain amount of difficulty. Neurology does not admit
of narrow specialism ; a cerebral or spinal haemorrhage, for instance, is in
its etiology and treatment cardio-vascular, and for the complete investiga-
tion and treatment cf diseases of the nervous system a thorough knowledge
of general medicine is indispensable. The difficulty of investigation, how-
ever, is more apparent than real if the scheme of 8tud3ang medicine
adopted in this work be followed. Our first duty, when dealing with a
widespread structure like the nervous system, is to localise the seat of mis-
chief : Is it, for instance, in the brain, cord, nerves, or sympathetic system ?
This accomplished, the second stage of the process, the diagnosis of the
nature of the lesion, is not generally difficult, for the position it occupies,
the age of the patient, his history, and the mode of onset of the illness will
generally afford us fairly certain bases for decision. A convenient method
of examining a case of nervous disease will be given below, and by bearing
in mind the two steps just referred to the student should not experience
much difficulty in diagnosis.

ANATOMY AND PHYSIOLOGY.

It follows from what has just been said as to the necessity of identifying
the locality of a nervous disease before we can diagnose its nature, that an
accurate knowledge of the anatomy and physiology of the nervous system
is essential. Anatomically the nervous system consists of Encephalon
(Cerebrum, Cerebellum, Pons Varolii, and Medulla), Spinal Cord, Peri-
pheral Nerves, and Sympathetic System. But such a division into
localities is purely artificial, because the cells and their processes connect
these parts together histologically, physiologically, and pathologically
by an endless series of intercommunicating cells and fibres.

1 600. The Neuron. — Histologically, physiologically, and pathologically the nervous
system consists of a collection of cells which with their processes are called neurons.
The nervo-oells are called the neuron-bodies, and the cell processes, which when
elongated form the nerve fibres (or nerve fibrils), are sometimes spoken of as dendrons,

692

§800}

THE NEURON

693

Bulb. \

Spinal Cord.

Anterior Horni
CeU.

{25

their ultimate branching prooesses being called dendriUa (Fig. 142). They are sup

ported in connective tissue known as neuroglia. One of the dendrons is longer and

larger than the others, and receives a special covering

in the shape of a medullary sheath aftar leaving the

neuron-body or cell ; this process is called the axis-
cylinder process or neuraxon. The neuron-bodies or

cells are found entirely in the grey maUer of the brain

and cord, or in the various ganglia, such as those of the

posterior roots or sympathetic system. The neurazons

in passing to their destinations are often of considerable

length ; they pass through and constitute the fibres or

white maUer in the brain and cord, where they form the

nerve fibres, and finally traverse the nerve trunka to

their destination in the muscles, skin, special senses, or

elsewhere. The words *' ganglion cell,'* "multipolar

cell," " neuron cell," and " neuron-body " are also

sjmonymous.
The different cells at one time were thought to be

connected with each other by means of the branching

ends (dendrites) of their processes. Doubt has recently

been thrown on this, but whether there is organic con-
nection between the different neurons or not, their

dendrites interlace and lie side by side, and a nerve

impulse can pass from one to another, either directly

or after the manner of an electrical inductive process.
Ascending and Deioending Degenenition. — ^A nerve

cell depends for its nutrition on the quality of the sur-
rounding matrix, just as the nutrition of a tree is

modified by the soil surrounding its roots. A nerve'

fibre appears to depend mainly on its originating nerve-
cell for its nutrition. When a nerve-fibre is divided

(or injured) the part on the side farthest from the cell

of origin rapidly degenerates (Wallerian degeneration).

It is evident, therefore, that the cell body has a power-
ful control over the nutrition of the nerve-fibre to

which it gives origin. This nutritional dependence of
the nerve- fibres on their cells of origin is one of the
leading facts in neuropathology, and it accounts for
those descending (motor) and (iscending (sensory) de-
generations which we shall meet with so frequently
(Figs. 147 and 148). Moreover, by means of the arti-
ficial division of nerve-tracts histologists have been
enabled to trace the course of nerve-fibres in the brain
and cord which would have been impossible of dis-
section.

Waldeyer's neuron scheme of the nervous system as
above depicted is not regarded by everyone as the
most scientific, but for clinical purposes it is the most
lucid and practical existing at the present time.

The functions of the intimate structure of the differ-
ent parts of the nervous system and the paths or tracts
along which the impulses are transmitted, have been
learned in three ways : (1) By laborious dissection
relatively little information was gained, though by
microscopic examination, aided by differential stain-
ing, important paths were revealed. (2) By experi-
ments on animals, Hitzig, Ferrier, Horsley, and others
discovered the functions of important parts of the cerebral cortex, and other facts
were discovered, upon which the brilliant results of craniectomy depend. (3) It was,

Nave Trunk.

Muscle.

Fig. 142. — Diagrammatic repr«.-
sentation of a Motor Neuron,
the upper level (Upper Motor
Neuron) being from brain to
spinal cord, the lower level
(Lower Motor Neuron) being
from anterior horn to muscle.
Compare Figs. 147 and 161—
i.e.. Motor Tract and Path of
Tabes.

694 THE NERVOUS SYSTEM [ § 601

however, by the application of the principle of Wallerian degeneration just enunciated
that the greatest information has been acquired concerning the tracts in the cord and
elsewhere. When a motor cell in the cerebral cortex, for instance, is severed by
injury or disease from the long neuraxon which passes from it down the spinal oord.
a descending degeneration takes place in the pyramidal tracts of the spinal oord
(Fig. 148). Conversely whenever the sensory nerve-colls in a posterior root-ganglion,
for instance, are injured, or their connections severed, an ascending degeneration
takes place up the columns of GoU or Gowers (see below).

§ 601. The Brain and Spinal Oord. — Looked at in its simplest form, the brain oonsisto
of a mass of white fibres (the corona radiata) spreading out towards the sur&oe like
a fan, or the petal of a tiger lily, the edges of which are covered by the grey cerebral
cortex. This sur&oe or cortex is amplified by means of foldings (convolutions)
which, in the genus homo are more numerous tiian in any other of the vertebrata
(Figs. 143 and 144). Unlike the spinal cord, the grey matter of the brain is found
ohiefly upon its surface. But in the interior, at its lower part, there are three mssoen
of grey matter which, from before backwards, are the corpus striatum, the optic
thalamus, and the corpora quadrigemina (two on each side). The corpus striatum
is divided into two grey masses (the caudate nucleus internally and the lenticular
nucleus externally) by a most important band of white matter, the internal capnUe,
which carries the conducting strands from one side of the brain to the opposite side
of the body and limbs (Fig. 147). Internal to the lenticular nucleus oomes the
anterior end of the thalamus.

In regard to its Functions (Fig. 145) the cortex of the brain may he divided roughly
into three parts, anterior, posterior, and middle third. The anterior third, or frontal
portion, is the seat of the intelleot. Gross lesions in this position may exist for a
long time without any symptoms other than dulness and stupidity, headache, and
perhaps vertigo and nausea.^ The posterior third, or roughly the occipital portion,
is the seat of vision and several other important sense perceptions. The middle
portion just in front of the fissure of Rolando forms the motor area. * The different
centres for movements of the limbs on the opposite side are shown in Figs. 146 and
146. It will be observed (and this will enable us to remember the position of these
centres) that the most complex movements, those of the lips and tongue, are farthest
forward and lowest down, nearest the frontal or intellectual region. Behind and above
this in order come the centres for the face, arm, leg, and (on the median aspect of the
hemisphere) the trunk. This order, it will be observed, is that of less and less com-
plexity of movement. These centres are not absolutely defined, but oveilie each
other. This, the Rolandic, region is called the motor area because (1) electrical
stimulation in animals gives rise to movements, (2) irritative lesions give rise to oon-
vulsions, and (3) destructive lesions in this position cause paralysis, of the respective
limbs.

DiSBASBS OF THB Bbain may be classed under circulatory lesions, tumours, inflam-
matory lesions, degenerative lesions, and functional diseases. Vascular lesions
(hsBmorrhage, embolism, thrombosis) are of sudden, tumours of more gradual, onset.
Functional diseases include hysteria, epilepsy, insanity, and neurasthenia. Syphilis
may affect the brain in four ways — endarteritis (leading to thrombosis), meningeal
affections, gummata, and degeneration, as in paralytic dementia. Gummata con-
stitute one of the most frequent forms of cerebral tumours.

Medulla and Spinal Oord. — Those parts of the bulb and the pons varolii which form
the floor of the fourth ventricle and the iter a tertio ad quartum ventriculum, contain
a series of grey nuclei which give origin to the cranial nerves. These form, as it
were, a continuation upwards of the anterior and posterior horns of the grey matter
of the spinal cord. Indeed, if we imagine the spinal cord to be split from behind, and
as it is traced upwards, to be opened outwards, so that the posterior grey comua
come to be external, and the anterior columns come to the sur&u>e beside tl^ middle

^ Apathy and somnolence were absolutely the only symptoms in a case shown by
Dr. Ferrier at the Neurological Society in 1892, and in two cases under my own care
at the Paddington Infirmary, in 1892, verified by autopsy. These symptoms occur
in monkeys deprived of their frontal lobes, but they sometimes recover completely, and
regain their faculty of attention.

§ 601 ] TUB BUAII^ AND 8P1NAL CORt) 69^

line, we should find, what is actually the case, that the motor nuclei of the twelfth,
eleventh, seventh, sixth, and the fifth cranial nerves (motor nuclei corresponding to
the anterior horns) lie on each side of the middle line, and that the sensory nuclei of
the tenth, ninth, eighth, and fifth nerves (corresponding to the posterior horns) lie in a
more external situation. The nuclei of the other motor nerves (fourth and third)
lie much farther forward beneath the aqueduct of Sylvius.

Functions. — ^The bulb contains important reflex and automatic centres. The reflex
centres are for the closure of the eyelids, sneezing, coughing, sucking, mastication,
secretion of saliva, swallowing, vomiting, dilatation of the pupil, and tibe vaso-motor
regulation (general dominant reflex centre). The automatic centres are respiratory,
cardio-inhibitory, vaso-motor, sweating, and convulsion centres. The convulsion
centre is situated just where the medulla joins the pons ; stimulation of it causes
general spasms. The centre may be excited by a venous condition of the blood, as
in asphyxia, ansBmia (as when the carotids are tied), or congestion, as in compression
of the veins coming from the head.

The ipinal cord in the adult extends from the margin of the foramen magnum to a
point opposite the first lumbar spine, and measures 16 inches. In the infant it extends
to the bottom of the spinal canal. There are enlargements in the cervical and lumbar
regions, containing the ganglion cells for the nerve supply of the upper and lower limbs
respectively. In the white matter of the cord, which is concerned in conducting
impulses upwards and downwards, certain columns have been mapped out by means
of developmental and experimental inquiries, and by studying the position of secondary
descending and ascending degenerations; these are shown in Fig. 148. The best
way to regard the grey matter of the cord is as a series of segments or discs, super-
imposed one upon the other, thirty-two in number, corresponding to the pairs of the
spinal nerve roots, each segment being concerned in the three functions of the cord —
viz., conduction, reflex action, and the regulation of certain neuro-muscular pheno-
mena.

The Motor Tract (Fig. 147). — It is important to remember that a motor impulse
passing from the cerebral cortex to the periphery must pass through two neurons :
(1) The upj>er motor neuron, connecting the cortex with a multipolar cell in the medulla
or cord ; (2) the lotver motor neuron, which consists of the multipolar cell in the anterior
horns of the cord, and the nerve fibre from this to the muscle fibres. A motor impulse
starting in the Rolandic area in the cortex passes through the corona radiata in the
central white matter of the brain, through the internal capsule — ^in which situation
all the motor fibres are collected into one small bundle occupying the anterior two-
thirds of the hinder limb — through the middle two-fifths of the cms cerebri of the same
side, through the pons in a band lying between the superficial and deep transverse
fibres, and through the anterior p3rramids of the medulla. Here the bulk of the motor
fibres cross to the opposite side to form the crossed pyramidal tract in the lateral
columns of the spinal cord. This tract diminishes in size from above downwards
as the terminal dendrites come into relation with those of the anterior multipolar
Cells (the dark band in Fig. 147, horizontal section in Fig. 148). At the point of decus-
sation in the medulla a few of the motor neuraxons, instead of crossing over, pass
down the same side of the cord in the anterior column close behind the anterior
fissure, forming the direct pyramidal tract which terminates about the middle of the
dorsal region. The lower motor neurons (the spino-musoular level) start in the multi-
polar cells of the anterior horns (or their analogues, the motor cranial nuclei), and pass
out through the anterior nerve roots (or the cranial nerves) into the peripheral nerve
trunks, and terminate in the muscles. The total number of fibres (neuraxons) of the
lower level passing out through the anterior roots is far greater than the number of
neuraxons in the upper level ; it follows therefore that one neuraxon of the cerebro-
spinal series must control several associated neurons of the spino-muscular level.

Taking a Jiorizontal section of the internal capsule (Fig. 154, 780), the motor fibres
in the genu supply from before backwards the eyes, face, and tongue. The motor
fibres in the anterior two-thirds of the posterior limb of the capsule supply from before
backwards the shoulder, arm, hand, trunk, and leg.

DsscENDiNO Sclerosis. — The cortical cells preside over the nutrition of the neur-
axons as far down as the anterior horns, and consequently a disease of the cortical

696

THE NERVOUS SYSTEM

l§601

CallOBo-margiiua flflfure.

FiBBUie of Eolando.

Cfl^OA/;.

Parieto-
occipital" •■ "5^*

flBBure. ^

CalcariBO^^' O'
flBBore. u

Fig. 148.

Fissure of Kolando.

LOBE

Interparietal
flisiire.

Parieto-
oodpltal
fissure.

Fissure of
Sylvius.

^^AfPORAL LOBE

Fig. 144.

Figs. 143 and 144.— Gontolutions and Fissxtbes of the Brain, external surface (lower figure)
and median aspect (upper figure) of the left cerebral hemisphere. The uncinate lobule is
sometimes called the gyrus hippocampus. This with the gsrrus fomieatus together form the
falciform lobule. The paracentral lobule is the posterior part of the marginal convolution.

cells, or a losion cutting off these cells from the fibres below, will be attended by a
degeneration (descending scleroiis) down the lateral column to the ends of these
neuraxons. The cells in the anterior horns of the spinal cord similarly preside over
the nutrition of the peripheral nerve fibres, and disease of these cells, or a lesion
cutting them off from the neurazon below, is followed by degeneration of the motor
nerves and atrophy of the muscles with which they are connected.

THE BBAIN AND SPINAL CORD

Fig. 14S.

Fi8>- lU and IM.— LooAUSAnOK of tBe Chiet FcNcmoirS on the cerehral cortex of the KioBt
HimsrBBIlS, outer BiufBce above, meillan Mpect below. — Ttt motor arta wu (ormerly located
botb Id front and behind the Suure of Rolando, bnt SherrlnKton and GrUnbaum'i leaeaichei
(Ttuii. Patb. Sac. Lond., i»02l, eonBrrued by Alfred CampbeU and attien, have tbowu that
it lie* wholly In front of thla fluure. Moreover, Commm Snttttion Is nov located bahlnd
tbe llHure of Rolando (see p. 7W|. Note. — The Sptceli Cenire occupies tJie poateTlor halt
_. ..._ ...._.. ..~ '-ontal coDvolutloD. It la Indicatad ou thii, the right bemliphere, only lor

THE NEBVOVS SYSTEM

[SO

We shall see hereaft«r that two important clinical facts follow iioni the
foregoing data which the student must always lemember.

First, all paralyses due to lesions of the upper motor nearcHu, situated
anywhere between the cortex and the anterior horns, are attended by
muscular rigidity, with increase of reflexes, but without muscular wasting,
because the multipolar cell of the
lower neuron remains intact. Con-
sequently, all hemiplegic lesions and
paraplegic lesions attended by lateisl
sclerosis are recognised by being

BIGID, NON - ATROPHIC, with IN-
0R£A8ED DEEP BEFLBXBS.

Secondly, the anterior multipolar
cells which start the lower neuron,
preside over the nutrition not only
of the peripheral nerves, but also of
the muscles with which they are
connected, and consequently lower
moUtt netuon lesions, on the other
hand, are characterised by being

FLACCID, ATSOPHIO, with LOBS 07
DEEP BEPLBZE8.

tnaX or 8rfl«m LmIou of tli* Ooii are
degenentive lesions limited to one oi
other vtHkal tract (Fig. p. 700). The
Bjmptome of these dimses differ from
lesioiiB, Buoh as trsnaverae myelitis, whioh
involve » horizontal ttgmenl of the oord.
(Table on opposite page.)

Fig. 117, — ItOTOR (dfaoonding mrron) AND
Sbssokt {ucendlns arrowil Triitts.— The
motot tTMit ihawiDg Ihs coana at the facial
flblM, the onMHd pytamldal tract (thLckl
aod the dlrwt pyramliU] tract. The leiuory
tract ihowi the cruMlug, at the iplnsl laval

—The Bongoiy or ceotripot*! tnwt is not
BO olearlj known as the motor, ohiefly
because of the diffianlty of twmintely
testing it in man and animals.

The peripheral afftrenl ntrvta may, from
the researohea of Head, Rivers, and
Sherrsn {Brain. 1906, the Lancet, 1011],
bo differentiated into three tj/glemi oc-
cording lo the tindt of eentation they

I. The £piCRiTic System of Sbres run
Ti the cutaneous nerves. They transmit
tactila sensation and the recognition ot
slight differenoes of temparatnre. Inter-
II loocn aua pain. ruptionof theseabolishes: (a) HeOognitiOD

of light touch {e.g., by oott4Hi-woal) ; dia-
le of object and compass points ; (b) outaneous localisation ; and (e)
ditcrimination of temperature between about 25° and 40° C.

2. The Pbotofathic Sistbh of fibres also run in the outaneoua oerveB, but by
fibres independent of the preceding. They transmit painful cutaneous senaationa
and extremes of tenptralim. Interruption abolishes : (a) Cutaneous pain (e.g., by
pricking or strong taradio currents) ; (6) cutaneous temperature sense below aboat

§502]

SENSATION AND THE SENSORY TRACT

699

Symptoms,

Tracts Affected.

Types of Disease,

Rigidity, increased re-
flexes, no wasting.

Crossed pyramidal traot. Lateral sclerosis.

Ataxy, loss of reflexes. ' Posterior columns.

Tabes dorsalis.

Flaooidity, loss of re-
flexes, wasting, and
K. D.

Ataxy, rigidity, in-
creased reflexes, no
wasting.

Rigidity, increased re-
flexes, some wasting.

Ataxy, tremor, and loss
of knee jerk.

Intention tremor, nys-
tagmus, and other
symptoms.

Anterior horns.

Anterior poliomyelitis,
acute and chronic.

Posterior columns, direct
cerebellar and crossed
pyramidal tracts.

Anterior horns and
crossed pyramidal tract.

A combined disease of
posterior and lateral
tracts.

Scattered patches of
sclerosis.

Ataxic paraplegia.

Amyotrophic lateral scle-
rosis.

Friedreich's hereditary
ataxy.

Disseminated sclerosis of
Charcot.

20^ C, and above about 45^ C. These fibres are the first to regenerate after section
of a cutaneous nerve.

3. The Dbbf Sbnsibility Systbm of fibres run chiefly in the nerves to the muscles.
They transmit deep preMnre sensations and mnictilar sensations. These are not
destroyed by dividing all the cutaneous sensory nerves. Loss of deep sensibility
abolishes : (a) Sense of movements (extent and direction) in joints, tendons, and
muscles (kinseethetic sense and position of a limb), as tested by distinguishing the
difference of weight of objects of similar size, or by ability to place one limb in the
same position as the other with eyes closed (compare § 503 below) ; (6) sense of pressure
(position and degree) in the deep parts, (c) Vibration sense. Normally a sense of
vibration is felt if a low-pitched tuning-fork is set in vibration and placed on the
surface of a bone.

The leading fact to remember about common sensation (painful, thermal, and part
of tactile) is that it enters the cord by the posterior roots (Fig. 147), and crosses to the
opposite side soon after entering, so that a unilateral lesion of the cord produces paralysis
of the same, anaesthesia of the opposite, side (Brown-S6quard's paralysis). After
entering the cord from the periphery the sonsory neuraxons take several different
routes. The joint sense, sense of active muscular contraction, and part of the tactile
sense, do not cross, but pass up by (1) the postero-extemal (Burdaoh's) column, and
the postero-median (QolPs) column. (2) Other fibres end in the grey matter of the
cord round cells whose axis-cylinders cross and ascend the cord in the antero-lateral
(Gowers') tract. (3) The direct cerebellar tract, passing on to the cerebellum. (4)
Another set of fibres passes into the grey matter of the cord and ends round the
anterior horn ceUs, thus forming the path of the reflex arc. The first three tracts pass
up to the medulla. GoWa and Burdach's columns form the funiculi in the medulla,
and fibres from these cross in the medulla and pass up together with Gowers* column
and the fifth cranial nerve (which joins the sensory tract at that part) in the lemniscus
or fillet which occupies the posterior part of the pons, through the tegmentum of the cms
cerebri, to the basal ganglia, where some of the fibres end. The sensory tract in the
brain then passes up through the posterior third of the hinder limb of the internal
capstUe (sensory crossway), coming« be it observed, from the opposite limbs. In this

700

THE NERVOUS SYSTEM

position it receives the visual and auditory fibres from the optic and auditory nerves,
and probably also from the nerves of smell and taste, all frx>m the opposite side. The
sensory tract continues upwards through the corona radiata. Some doubt has
hitherto existed as to the part of the cortex subservient to sensation. Sir Victor
Horsley originally located common sensation in the gyrus fomicatus, and the author
recorded a case^ where a localised lesion in this situation was attended by hemian-
8B6thesia. But the most recent researches of Sherrington and Griinbaum in animab,
Horsley 2 and Gushing^ in man, seem to indicate the ascending parietal convolution
(post-central gyrus) as the more probable position (Fig. 145). The last-named ob-
server stimulated the post-central gyrus of a conscious patient by imipolar tea-
disation.

§ 508. The Oerebellam, Oo-ordination, and Eanilibrium.— In order that our balance
in the erect posture may be preserved and our different muscular movements effective.

Fig. 148. — Traksvkrsb Section of Spinal €k)RD in tlie oervioo-donal region. — Dbsouidino
Dbosnbration talces place chiefly in the crossed pyramidal trsct and direct pyramidal tract :
chief ASOENDINQ Deqbneration in the columns of Qoll and Bordach, Oowers* tract, direct
cerebellar tract, and to a lees extent in the spino-thalamic fibres running in the cioited pyra-
midal tract. The fibres for pain and temperature and some of those for tactile sensibility
pass up the spino-thalamic tract after crossing. The fibres for the Idnnsthetio, together
with the remainder of those for tactile sensibility, all uncrossed, and Joint senses nm in the
posterior columns.

the contractions of the various muscles must bo co-ordinated or correlated to one
another. The centre for this co-ordination appears to lie in the cerebellum, and
especially in its middle lobe. The cerebellum consists of two hemispheres and a middle
lobe. It is connected above with the cerebrum by the superior peduncles, below
with the medulla by the inferior peduncles, and in front with the pons varolii by the
middle peduncles — cerebro-afferent fibres. In order to co-ordinate the various
movements and to preserve equilibrium of the body, the cerebellum must be kept
correctly informed of the relation we bear to surrounding objects, and also as to the
state of contraction of the various muscles. This is accomplished by four different
sets of afferont or in-going impulses. (1) The sensfUion of touch of surrounding
objects is transmitted through the paths of common sensation. (2) The sight of
surrounding objects informs us of our relation to them, and therefore it is assumed
centripetal fibres pass from the centres for movement of the eyeballs and sight to the
middle lobe of the cerebellum, to assist in regulating the attitude of the body so far

1 Brain, 1891, p. 270. ^ Brit Med. Joum,, July 17, 1909. ^ Brain, part i.. 1909.

$ft04] THE CEREBELLUM 701

as it relates to the maintenance of our proper distance from the objects around us.
It is possibly in this way that nystagmus comes to be a symptom of cerebellar tumour.

(3) OrienUUum, or the position in which our body lies at any given moment in
relation to vertical and horizontal planes, is recognised by impulses coming from the
Bomi -circular canals, transmitted through the vestibular portion of the auditory nerve
to the cerebellum. Disease of the semi-circular canals or of this nerve produces a
feeling of giddiness or unsteadiness, and there may be an inability to stand {e.g.. in
M^ni^re's disease).

(4) Sense of Active Muscular Contraction {Kinosstheiic Sense) and Joint Sense. — A
knowledge of the state of contraction of the muscles is recognised as necessary for the
preservation of equilibrium and co-ordination. The kintesthotic sense tract starts
in the muscle spindles.* It passes through the norves into the spinal cord by th^
posterior root, up the columns of Goll (postcro-median columns), and the direct
cerebellar tracts to the middle lobo of the cerebellum. The columns of GroU transmit
this sense from the lower extremities ; the direct cerebellar tracts from the upper
dorsal and cervical regions chiefly. Interruption of these tracts is the principal factor
in the production of tabes dorsalis (§ 578, Fig. 161 ).

Destruction of any one of those four tracts disturbs equilibrium more or less. For
instance, in tabes dorsjilis there is generally aneesthesia of the soles of the feet (1 above
is destroyed), and the kiniesthotic and joint sense (4) is also disturbed, so that when
the eyes are shut and path 2 is interrupted, the patient tends naturally to fall {Rom-
berg's sign).

CerebeUo- Efferent Tracts. — The cerebellum only regulates, it does not initiate,
muscular contractions. These are started by the cerebrum, and are merely controlled
by the subordinate centre in the cerebellum. The connection of the cerebellum with
the cerebral hemispheres is mainly a crossed one, fibres passing from the cerebellar
hemisphere of one side to the cerebral hemisphere of the opposite. Lesions of the
cerebellum produce (I) a staggering or reeling gait, and a deficiency in equilibrium,
but they do not produce absolute paralysis. Lesions in the upper part of the middle
lobe produce a tendency to fall forwards ; those of the lower part to fall backwards ;
and if of the lateral lobe, the patient may show a tendency to fall towards the affected
side, or there may be forced rotary movements towards the affected side. Tumour
of the lateral lobe may produce inoo-ordination and paresis of the limbs on the same
side, from pressure on the motor tract or from affection of the contra-lateral cerebral
centre.

§ 504. The Membranat of the Brain and Spinal Oord should be mentioned together,
as they are indentical in structure, continuous with one another, and subject to the
same diseases.

The membranes of the brain and cord are subject to a great many lesions. (1)
Meningitis is inflammation of the membranes ; several different forms are recognised,
(i.) External or pachymeningitis begins and predominates in the dura, (ii.) Internal
or lepto-meningitis is inflammation which begins and predominates in the pia and
arachnoid, (iii.) A specific epidemic form of meningitis is recognised, which consists
of a lepto-meningitis in which the pneumococcus of Fraenkel has been found, (iv.)
A septicsBmic form of meningitis is recognised, which is apt to complicate scarlatina
and other acute diseases. Meningitis has also been traced to syphilis and bacterial
processes. (2) Tubercle is one of the commonest diseases affecting the meninges in
children. It involves the pia mater and arachnoid, and almost invariably starts and
predominates in the transverse fissure and fissure of Sylvius. (3) Syphilitic gumma
of the meninges is the commonest meningeal disease in adults. Syphilis also produces
simple thickening of the meninges and disease of its arteries. (4) Cancer chiefly
affeote the dura mater secondarily to cancer in other parts of the body. (5) Fibrous
thickening of the dura is found as a chronic form of pachymeningitis. (6) Bony
plates may be found as the residt of a chronic meningitis. I have generally found
them in the arachnoid, and chiefly in old people. (7) Hssmorrhage may take place
in both the meninges of the brain and coid. In the former position it is known as
hiemorrhagio pachymeningitis, and in the latter hflsmatorrhachis. The blood may

* F. E. Batten, Brain, 1897, partjxx., p. 138.

702 THE NER VO US 8 Y8TEM [ § b05

be effused in three positions ; it may be extradural, subdural, or subarachnoid.
(8) Finally, the meninges of either brain or cord may be the seat of injury.

In all these disorders the disease may start or predominate either in the cranium or
the spine, but it is very apt to spread to the other. It must also be remembered that
the surface of the brain and spinal cord derive their nourishment almost entirely from
the pia and arachnoid which invest them, and therefore diseases of the membranes
impair their nutrition considerably. And since the cortex of the brain is the most
important part functionally, grave consequences may ensue from meningeal diseases,
f 505. The Cerebral Circulation. — The artebiss of the brain are derived from two
internal carotids and the vertebrals, which form the circle of Willis (Fig. in § 552).
The middle cerebral is the most important artery of the brain, and it is a continuation
onwards of the internal carotid. The internal carotid (which arises from the highest
part of the aorta) and left middle cerebral are in a direct line for emboli from the
valves of the heart. There are two series of branches of the middle cerebral,' the
external branches and the internal branches. The left Sylvian artery, which in-
stitutes the chief supply of the internal capsule, is also in the direct line from the
heart, and as it feels the full ventricular shock it is frequently the seat of haemorrhage.
For the same reason also it is frequently the seat of embolism in younger persons,
and this accounts for the greater frequency of right hemiplegia in circulatory lesions.
Figs. 149 and 150 show the vascular areas supplied by the cerebral arteries.

Vbiks Ain> SiNTTSBS. — ^The venules collect the blood into veins of the brain (which
liave no valves), which enter the cerebral sinuses backwards. Most of the blood
leayes the cranial cavity through the internal jugular veins, which are continuations
of the lateral sinuses. Should they be blocked, there are a few collateral communica-
tions through which the intracranial circulation communicates with the veins outside
the skuU. Thus (1) the interior end of the superior longitudinal sinus communicates
with the veins of the nose ; (2) the ophthalmic veins communicate through the orbit
with the facial veins ; (3) the lateral sinus communicates with the occipital veins
through the mastoid cells ; (4) the superior longitudinal sinus communicates through
the calvarium with the veins of the scalp ; and (5) the inferior petrosal sinus com-
municates with the deep cervical veins. The veins of Qalen collect the blood from the
collateral plexuses in the lateral ventricles, and empty themselves into the straight
sinus, and thence into the toroular Herophili and through the lateral sinus into the
internal jugular vein. Pressure on or thrombosis of these veins produces distension
of the lateral ventricles with fluid (hydrocephalus) if the foramen of Majendie be
occluded.

The Pbouliabitibs of the Cbbbbral Circulation are as follows : (1) There are
no anastomoses between the arteries of the cortex and those of the interior of the
brain ; there are no anastomoses between the several branches in the interior, and
only very few between the several cortical branches, each of which supplies its own
areas. (2) There are no communications between the several branches of the verte-
bral, basilar, and cerebellar arteries, which supply the pons and bulb ; but the superior,
middle, and inferior cerebellar arteries communicate freely, hence the greater
frequency of vascular lesions in the former as compared with the latter positions.
(3) The cranium being a rigid box the quantity of blood in it is always the same, but
the velocity varies considerably, and the velocity depends on the blood-pressure in
the carotids and vertebrals. The blood-pressure in these varies inversely as the
dilatation of the splanchnic area, and the rapidity of the cerebral circulation, it seems
quit* clear, is regulated mainly by the great reservoir in the splanchnic area. When
this is dilated the general blood-pressure is low, and the circulation in the brain is
slow ; conversely, when the splanchnic area is contracted, the general blood-pressure
is raised, and the circulation of the brain becomes more rapid. Dr. Leonard Hill
maintains that there is no vaso-motor regulation of the cerebral arteries, a fact which
is hard to believe in view of the amount of involuntary muscular tissue present in
these vessels. Professor Sherrington maintains that they have the same nerve-
supply as the other vessels. At any rate, high blood-pressure in the carotids, and
therefore in the cerebral circulation, is attended with rapid circulation in the brain
(wakefulness), and conversely low blood-pressure is attended with slow cerebral
circulation, as in sleep.

itM] THE OEREBRAL CIRCULATION 703

i 6H. The Srmpkthttla Vflrrouj Sritam is Almost &s exteiuive and elaborate u the
oorebro- spina] nervous system, with whioh it is intimfttely conneoted. The Bym-
pathetio sjBtem oonaiBts ia the main of a double series of ganglia arranged aloog the
vBDtral ospeot of the vertebr»I oolumn. In the abdomen these ganglia are massed
*ad matted together Into the oceliao plexuses and semiluosr ganglia, which evidentt;
oomtitute the chief centres, the " br»in." as Hi wore, of the Hympathetic system.
The sympathetic ganglia are connected by non -medulla ted fibres with one another.

with the oranial Tietvee. with the anterior and posterior roots of the spinal oonl, with
all the arteries (aronnd which they form plezoses), and with all the unstriped muscular
tiwue of the body — namely, that of the arteries and that of inteatlaea and other
viscera. The only named branohes are the greater and lesser splanohnia nerves.
' One funotjon of the sympathetic system ie to regulate the flow of blood through
the arteries by means of their tunica media or muaonlar ooat. and thna to control
and co-ordinate the various vaaouUr areas one with another, and regulate the nntritJon
going to the tissues and viscera. It has b(>en shown {by Dr. Leonard Hill, for example)

704 THE NERV0V8 SYSTEM [ % 507

that the cerebral circulation is mainly regulated by the contraction and dilatatioa
of the vascular area (the splanchnic) within the abdomen. Stimulation of the sym-
pathetic fibres to the heart accelerates that organ. This system also regulates the
intestinal movements, and therefore the alimentation of the body. It also regulates
the secretion of various glands either directly or indirectly through the vessels which
supply them. The pathological effects are most definitely recognised in the case of
paralysis of the cervical sympathetic (§ 612). In the author's view the S3rmpathetic
system is also largely responsible for most of the phenomena of hysteria, many of
those ascribed to neurasthenia, and some of the other so-called functional diseases of
the nervous system.

§ 507. Oeneral Prinoiplat in Neuro-pathology. — (1) Whenever the nutrition of a
neuron is impaired, the peripheral endings of its processes (dendrites) are the first to
show degeneration. An illustration of this is seen in tabes, where the peripheral
termination of the muscle-sense neuraxon in the muscle spindle is the first to undergo
degeneration. This principle, which h^s a widespread application in neuropathology,
is the outcome of the fact that the cell or neuron-body is the most essential and vital
part of the neuron, and controls the nutrition of the neuraxon and dendrites. Conse-
quently, when the neuron as a whole suffers firom want of nutrition or other cause of
degeneration, the psaie farthest from the cell first show the degenerative change.

(2) Prolonged forced functioning of any nerve structure results in its atrophy ; it also
results in the predominance and overpowering of that structure by the surrounding tissues,
and a final degeneration of the fatigued structure. This is sometimes known as Edinger's
theory, but it is a principle with which neurologists have long been familiar. A
typical instance of it is seen in the tremor, spasm, and atrophic paralysis which
accompany various occupation neuroses. It explains also the predominance of tabes
in the male sex, who use their muscle-sense neurons so much more than females, and
it also explains the fact why tabes supervenes during the prime of manhood, at a
time when the muscle-sense neurons are exercised most.

(3) Sclerosis is a consequence, not a cause, of the atrophy of the parenchymatous tissue-s
(nerve structures proper). This is a general pathological principle, which is applicable
also to the nervous system. It was formerly thought that the occurrence of fibrous
tissue in cirrhosis of the liver, or fibrosis of the kidnsy (contracted granular kidney)
was the cause, by pressure, of the atrophy of the glandular cells, but modem pathology
teaches the converse of this, and shows how true was the statement of Cohnheim,
made about the year 1860, that ** the mutual resistance of tissues to each other *s
encroachment, limits tissue growth normally. If you remove one tissue element —
by degeneration or otherwise — the surrounding tissues (deprived of this opposition),
tend to take on increased activity, growth, and proliferation." An application of
this principle is seen also in tabes, where, as a consequence of the degeneration and
atrophy of the muscle-sense neurons, secondary sclerosis occurs of the posterior
columns, in which the muscle-sense neuraxons lie. It is seen in many other scleroses
of the spinal cord.

(4) Functions which are last acquired in the evolution of the nervous system are the first
to succumb to disease, and vice versa. One illustration of this principle is seen in mental
disorders, m which the latest acquired faculties of the mind are those which most
readily become disordered. Again , in aphasia (loss of memory for the signs of thought),
the memory for printed or written signs is lost more often and sooner than the memory
for spoken words.

PART A. SYMPTOMATOLOGY,

The most constant and cardinal symptoms of diseases of the nervous
system may be subjective or objective. Among the objective symptoms
defects in miucular power are the most obvious, because the muscular
system is entirely dependent on the nervous system ; and these will be
considered seriatim under Paralysis, Inco-ordination, and Disordered Oait,
Muscular Ridigity, Tremor, and Amyotrophy, in Parts B. and C. Defect!
of sensation and the special senses will also be there considered.

§§ 608. 509 ] S YMPTOMA TOLOQ Y—NER VO U8NE88 705

The subjective symptoms met with in disorders of the nervous system
are very numerous, but they can practically all be brought under one of
six headings — defects of the mental powers, nervonsnesSy pain (including
headache), disordered sleep, vertigo, and disordered sensations.

The mental powers are disturbed in greater or less degree in most
diseases of the nervous system, particularly in those of the brain. Gener-
ally there is inaptitude for mental work ; sometimes there are transient
disturbances of thought ; at other times there is stupor, mental apathy,
or coma. Sometimes there is a loss of speech or of memory, or some
other faculty of the mind. Sometimes there is restlessness, excitement,
or delirium ; at others there is a more chronic perversion of the mind,
which amounts to insanity. A simple epitome of these various symptoms
and their causes occupies many pages (§§ 537 to 542).

In the mental symptoms which arise in certain inflammatory and other
diseases of the brain it is useful to remember that delirium, convulsions,
and headache are evidences of cerebral irritation, whereas mental dulness,
stupor, paralysis, and coma are evidences of cerebral compression or intense
toxsemia.

§ 508. Nervousness is a symptom which frequently guides us to dis-
orders of the nervous system. In its colloquial sense it generally means
"easily agitated." The patient comes to us, for instance, because the
least noise startles him or the least worry upsets him. (1) It is the leading
and most constant symptom in neurasthenia, an asthenic state of the
nervous system (§ 523) arising from gastro-intestinal or other toxsemia,
malnutrition, fatigue, accident, or some emotional strain.^ (2) Hysteria
is the next most common cause of nervousness. But here we have au
inherent emotional and vasomotor instability, which is manifested by
"hysterics" and various other forms of attack.^ (3) In a great many
structural diseases of the nervous system the patient comes to us for what
he calls nervousness, particularly in those which will be mentioned under
the symptom tremor. (4) Chronic alcoholism, morphinism, and their effects,
are manifested by nervousness ; and (5) convalescence from severe illness
and many other debilitated conditions are also attended by nervousness.

§ 509. Pain and Neuralgia. — Pain is a subjective symptom of con-
siderable frequency in all diseases, but not more in those of the nervous
system than other systems unless the peripheral nerves are involved. We
know but little about the psychology and pathology of pain, but a careful
clinical observer may derive considerable help by investigating the four
important qualities which I have many times mentioned : (1) Its position ;
(2) its character — whether throbbing, pricking, shooting, knife-like, dull,
aching, etc. ; (3) its degree ; and (4) its constancy — i.e., whether persistent
or intermittent, or a combination of the two (paroxysmal or exacerbating).
We should never allow ourselves, for the sake of time or trouble, or by
pandering to the ignorance or whim of our patients, to treat pain simply

^ ** Clin. Leots. on NenrMthenia/' fourth edition, Qlaisher and Co., London, 1909.
3 ** LeotoroB on Hysteria/' Glaisher, London, 1909.

706 THE NBR VO US 8 Y8TEM [ § 609a

as pain, by the administration of soporifics, hypnotics, and the like. Pain
is a sure indication of abnormal structure or function, and it is our boundea
duty to endeavour to trace out its causal agent, however difficult the task
may be. The best method of investigating the cause of a neuralgia or
pain in any given case is, first, to examine the nerve apparently involved
in the pain, and the locaiity around, for direct causes of irritation, and
particularly any bony orifice through which the nerve passes ; secondly,
to seek for any reflex cause of irritation in disease of organs more or less
distant, such as the teeth or the uterus ; and, thirdly, to search for any
general or constitutional derangement which may act as a predisposing or
exciting cause, such as anaemia, rheumatism, gout, tubercle, or syphilis.

Pain and Neuralgia in different parts of the body and limbs are
discussed fully imder Neuralgia (§ 604).

§ 609a. Headache (Cephalalgia) is often met with in diseases of the
nervous s3nBtem, but it quite as often attends morbid conditions of some
other, and particularly the vascular, system. Its generalised distribution
on both sides (a feature which distinguishes it from neuralgia of the fifth
nerve) suggests that it is due in most cases to disturbances of the circula-
tion within or outside the cranium. Frontal, vertical, and occipital
headache were believed by Dr. Hughlings Jackson^ to indicate an ab-
dominal, cerebral, and circulatory origin respectively, but the position
of the pain is not, in my experience, much guide to its cause.

The Causes of headache are numerous, and do not admit of pathological
classification, but inquiries should be directed to possible Local, General,
and Reflex causes, as in the case of pain and neuralgia.

(a) Among the following Local Conditions, the first five cause con-
tinuous pain of some duration. (1) Syphilitic disease of the cranium is a
frequent cause of continuous headache, and a marked feature of this
headache is its nocturnal exacerbation and its associated tenderness.

(2) Various meningeal conditions, acute or chronic, cause pain, and here
syphilis again may play a leading part. In children tuberculous menin-
gitis should always be suspected, and the temperature carefully taken.

(3) Intracranial tumours, especially when affecting the meninges or cortex,
may be known by the association of vertigo, occasional vomiting (especially
when the headache is worst), and optic neuritis ; localised tenderness over
the seat of the lesion is sometimes observed. (4) Ear disease causes head-
ache, and in such cases pressure over the mastoid cells often reveals
tenderness. (5) It must also be remembered that disease of the frontal
sinuses, which is usually secondary to nasal or post-nasal catarrh, gives
rise to dull, continuous headache. (6) The sufra-orhital branch of the
fifth nerve supplies the forehead, and neuralgia of this nerve necessarily
produces frontal headache of a shooting and paroxysmal character. (7)
Excessive brain work is frequently followed by a feeling of dull, heavy
weight on the vertex. (8) The wearing of hard and heavy hats.

^ Quoted by Dr. J. S. Bristowe, " Prin. and Pract. of Med.," fourth edition, London,
1882.

610] HE AD AGUE 707

(6) Among the Constitutional or General Conditions the first seven
causes mentioned below are due to toxic or hsemic conditions, and perhaps
eight and nine also. All of them are apt to have periodic exacerbations.
(1) Chronic interstitial nephritis should always be suspected in the aged,
a suspicion which is confirmed when the patient frequently rises at night
and passes large quantities of urine of low specific gravity. (2) High
arterial tension is probably in operation in the foregoing, but from whatever
cause arising is a very frequent source of headache. Indeed, it is gener-
ally the earliest and most pronounced symptom which attracts the patient's
attention. (3) Hefoiic derangement and the condition known as lithcemia
give rise to what is sometimes called bilious headache. (4) Chronic
alcoholism, gout, rheumatism, syphilis, and plunUnsm are also attended by
headache. The syphilitic headache is so severe as to interfere with work.
(5) Malaria, though rarely seen now in this country, is attended by a
severe frontal headache ; hence the term " brow ague." (6) Pyrexia, due
to any cause, is usually accompanied by headache. (7) GUorotic patients
sufEer a good deal from headache, but it has no special features beyond
the concurrent signs of anaemia. (8) Closely allied with the preceding is
the headache of exhaiistion or inanition. (9) Headache is frequent in bad
air, in hot and unventilated rooms. (10) Hysteria and r^eurasthenia are
frequently attended by headache. The first is often likened to a nail
being driven into the skull at one spot (hence the term " clavus " applied
to this headache) ; the second very frequently takes the form of a feeling
of constriction around the head (" casque neurasthenique " of Charcot).
(11) Migraine, which is a special paroxysmal form of headache is de-
scribed in § 605.

(c) Reflex Causes. — (1) Asthenopia or eye-strain is an extremely
frequent cause of headache in modem times, and is generally associated
with some uncorrected error of refraction or astigmatism. It may arise
without any error in those who read small print too much. This kind ol
headache has, in my experience, fairly constant characters — viz., it is
worst on rising in the morning, improves a little, and then again gets worse
after the day's work. (2) Constipation, (3) Dyspepsia and derangement
of the stomach are certainly amongst the most frequent causes of head-
ache in everyday life. It is said by some to be situated in the frontal
region, but in my belief it has no special characters beyond the sissociated
symptoms of these maladies. (4) In diseases of other viscera, especially
of the heart, lungs, uterus, and liver, a pain referred to the head is often
present. The headache of heart disease is often known as congestive
headache, and is certainly best relieved by cardiac depressants or bleeding.

The palliative Treatment of headache as a symptom will be found under
Neuralgia and Migraine, §§ 604 and 605.

§ 510. Disordered Sleep is not exclusively connected with nervous dis-
orders. We have to rely very much upon a patient's own acccount, and
sonie care is required in accepting his statement in this matter. Persons
differ considerably in the amount of sleep they require. The aged will

708 THE NER VO US 8 Y8TEM [ § 610

do with half the sleep of adolescence, and the middle-aged with half the
sleep of babyhood, the respective quantities being approximately five and
ten hours, eight and sixteen hours. Brain workers and town dwellers
require more sleep than labourers and country folk, though as a rule they
get less. The popular belief that " six hours for a man, seven for a woman,
and eight for a fool" is sufficient sleep is highly fallacious. Sir William
Jones' adaptation in the eighteenth century of an old Persian saying —

^* Seven hours to work, to soothing slumber seven,
Ton to the world allot, and all to Heaven,"

comes much nearer the truth, and my own belief is that a town life, with
brain work, requires at least seven or eight hours of quiet and uninterrupted
sleep.

Sleep may be (a) deficient in quantity (insomnia), or (6) defectivb
in quality (restlessness, dreaming, etc.) ; these generally coexist, and
their causes are interchangeable, (c) It may be excessive in quantity.
Normal sleep is attended by anaemia of the brain. The causes of (a) and
(h) depend either on inherent irritability of the brain or an excess or
defect in quality (toxaemia) of its blood supply.

(o) Insomnia, wakefulness, or deficient sleep may arise under the follow-
ing conditions : (1) All fainful affections are apt to be attended by sleep-
lessness. (2) Defective hygienic conditions or mode of life — e.g., late hours,
late suppers to those unaccustomed to them, indigestible food, overwork
of mind or body, unaccustomed surroundings and the like. (3) In neuras-
thenia, hysteria, and other functional disorders of the nervous systemy
mental excitement, all acute and many chronic forms of mental derange-
ment, sleeplessness may be one symptom of the ailment. (4) In the
absence of any of the foregoing causes, search should be made for some
general constitutional condition. Sleeplessness, like headache, in the aged
should always make one suspect chronic interstitial nephritis. Such
patients often complain of "cat-sleeps" — i.e., dropping off for a few
minutes at a time. (5) Among local disorders, cardiac valvular disease
may be mentioned, in which the patient starts up as soon as he falls off
to sleep with a feeling of suffocation.

(6) Defective Sleep. — (1) Dream-disturbed sleep, in my experience,
generally indicates a toxaemia of some kind. Nightmares and dreams in
the young are often due to an undigested meal taken late. They are also
a characteristic symptom of neurasthenia, anaemia, deficient oxygenation,
and various other toxic conditions of the blood. (2) Night terrors in
children are sometimes induced by worms or late suppers, or other dietetic
or gastro-intestinal defects — especially in nervous children. Among other
causes may be mentioned nasal or pharyngeal obstruction {e,g,, adenoids).
If continual, they should make us suspect petit mal, especially when
combined with nocturnal incontinence. There is a residue of cases in
which no cause is apparent excepting the neurotic diathesis, which subse-
quently becomes manifest by the development of hysteria, epilepsy.

§ 510 ] DISORDERED SLEEP 709

chorea, or mental degeneracy.^ (5) Sle&p-uoalhing and sleep-talking are
curious phenomena in which certain functions of the brain are not only
awake, but sometimes in an exalted condition. They are allied to hysteria,
and the same treatment applies. Here again petit mal may be in opera-
tion. (4) Twitching of the limbs as a person drops off to sleep may be an
early symptom of peripheral neuritis or of neurasthenia. It is a common
symptom of some toxoemias (particularly those of intestinal origin) on
the one hand, or hypersensitiveness of the nervous system (such as occurs
after morphinism, § 527) on the other. In all of these the twitchings may
pass on to intolerable restlessness.

(c) Excessive Sleep. — ^Drowsiness is a symptom met with in the
intense venous congestion of heart disease ; it is also an early symptom of
acute urcBtnia. In some other toxic states, and some organic hrain affections
(especially tumour in the region of the third ventricle), sleeplessness is
met with, and in all of these it tends to pass into stupor (§ 526). But
sometimes it is met with in apparent health. I was once consulted by
a curate who went to sleep almost as soon as he sat down in church during
certain parts of the service, or when his rector was preaching — a most
inconvenient circumstance. In that case it was apparently due to Uthcemia
and disordered liver, which being remedied, the sleepiness disappeared.
Dysfepsia (when the somnolence follows meals) and anosmia are common
causes of sleepiness during the day and wakefulness at night. In hysteria,
attacks of sleep (narcolepsy) may supervene at unexpected times. The
trypanosoma, when affecting the cerebro-spinal fluid, produces " sleeping
sickness," in which the patient sleeps for days, and then generally dies.
Persistent and even fatal sleep has been known to follow inflttenza. Cases
have been recorded in which sleep lasted for several days at a time ; the
attacks of sleep were prevented by the administration of thyroid.^

The Treatment of insomnia must be directed to the cause. It is in cases
of sleeplessness with or without pain that hypnotism is sometimes of
value. Among the simpler remedies, I have often found useful a cup of
warm milk or gruel, or a hot bath or hot-pack, last thing at night.
Dyspepsia after the evening meal must be carefully treated. Sometimes
an evening walk is useful, or Swedish and deep-breathing exercises, or
some means which take the mind away from the occupations of the day.
Massage or cold compresses over the legs or abdomen may promote sleep.
Sod. hypophosphite, 20 grains, in warm milk or milk and water at bed-
time is a simple yet excellent remedy for the sleeplessness of mental
fatigue, or bromide of ammonium, 20 grains, thrice daily, or an alkaline
draught of 30 grains of bicarbonate of soda in a tumbler of hot water.
A weak galvanic current through the brain or high frequency currents
I have sometimes found very good. When these simpler measures are
unavailing, recourse may be had to hypnotics and sedatives — care being
taken not to engender a habit — such as the following : Alcohol, chloral

^ See also a clinical lecture by Dr. Leonard Guthrie, Clinical Journal, June 7, 1899.
^ Dr. Lewis Bruce, ScotUish medical and Surgical Journal, December. 1910.

710 THE NERVOUS SYSTEM [ § 511

hydrate, camphor, cannabis indica, hyoscyamine, lupulin, paraldehyde,
bromidia, chloralamide, chlorobrom, snlphonal, veronal, trional, chlore-
tone, bromural.

§ 611. Vertigo is a subjective sensation experienced by a patient that either he or
the objects round him are rotating, accompanied by a momentary loss of equilibrium.
The latter may be so marked as to lead to a reeling in the gait, or actual falling do wo.
The symptom is sometimes difficult to elicit without putting a leading question* but
it is best to ask the patient if he has " any sensation *' in the head. People describe
it sometimes as a ** giddiness/* a " dizziness." or " swimming in the head." The
rotation may appear to be horizontal, vertical, or oblique. The sensation is often
attended by nausea, and intense giddiness, from no matter what origin, may be
sufficient to cause vomiting.

The Causes of vertigo may be mentioned under six headings : (a) Diseases of the
ear, (6) diseases of the nervous system, (c) diseases of the eye, (d) diseases of the ciroula-
tory organs, (e) affections of the stomach (gastric vertigo), and (/) laryngeal vertigo.
The first thing to do in any given case of vertigo is to decide whether it be accompanied
by any defect of hearing or not, as being the commonest cause.

(a) Aural VsBTiao. — ^Any disease of the external meatus. Eustachian tube, or
middle ear, which is accompanied by alteration of pressure on the fenestra ovale, is
usually accompanied by giddiness, and almost invariably by defective hearing. The
deafness, which may perhaps be sb'ght, may be either obstructive deafness, such as arises
in chronic middle-ear catarrh, or nerve deafness, such as that in labyrinthine disease
(see M6ni^re's disease, § 529a). These conditions are mentioned as the commonest
in the two classes named, but there are many other less common forms of obstructive
deafness and nerve deafness which are attended by vertigo (§ 618a).

(6) Diseases of the Nervous System. — (1) In epilepsy, vertigo often constitutes
the aura or warning of convulsive attacks (grand mal) and the whole phenomenon
in slight attacks of minor epilepsy (petit mal). It may be known by being invariably
accompanied by a temporary interruption of consciousness, however slight the attack,
and by a history of similar attacks dating from about fourteen to twenty years of
age. (2) Hysteria, neurasthenia, or any exhausted or depressed condition of the
nervous system, such as that produced by drugs, alcohol, or mental strain, may be
accompanied by giddiness. Hysterical vertigo generally comes on only when the
patient is startled or frightened. Neurasthenic vertigo is usually apt to come on
when the patient goes out of doors. (3) Various intracranial lesions in diffierent
situations may give rise to giddiness. Intracranial tumours in general, but especially
those affecting the cortex, cause vertigo, and are usually also accompanied by head-
ache, vomiting, optic neuritis, and perhaps convulsions, together with paralysis of
Btfme of the cranial nerves. Vertigo is a very marked feature in lesions of the cere^
bdlum or its peduncles, and here giddiness and a reeling gait are often the leading
and sometimes the only symptoms. (4) Disseminated sclerosis is attended in three-
fourths of the cases (Charcot) by vertigo. A disease has been described under the
name endemic paralytic vertigo, occurring in Switzerland and Japan, characterised by
paroxysmal vertigo and paralysis.

(c) In regard to Giroulatory Disorders (1) giddiness constitutes the first stage of
syncope, which may stop short at vertigo. In this way any condition of debility, or
poverty of blood, anssmia, convalescence, or exhausted states of the system, may give
rise to giddiness. Ansemia is perhaps the commonest cause of vertigo in the young.
(2) Any cardiac weakness or dogeneration, or disease of the coronary arteries, may
give rise to vertigo, especially among the aged. Excessive smoking, by acting as
a cardiac depressant, may act in the same way. (3) Arterial disease is attended by
vertigo, which even more than the preceding is characterised by coming on chiefly
when the patient rises from a sitting or stooping posture. This Senile Vertigo, or as
I have elsewhere described it,^ postural vertigo, very often occurs on rising at night
to pass water, or on first getting up in the morning (and see { 529). (4) Vertigo in

^ British Medical Journal, January 23, 1897, and Transactions of the Pathological
Society of London, 1904.

S51«] VERTiaO 711

the aged may be the only indication at the time of their occurrence of the minuU
hmmorrhages or softenings bo often found in their brains after death. (5) High Hood-
pressure arising from various permanent or temporary causes, as, for example, excess
of uric acid in the blood, is not infrequently attended by slight giddiness. Apart
from the actual occurrence of hsemorrhage, vertigo in the aged may always be taken
at a warning of some kind of cardiac or vascular failure, and the circulatory system
should be carefully investigated.

(d) Ocular Vbbtigo is usually due to weakness of one or other of the ocular muscles.
It is not uncommon in cases of myopia, in which the constant strain of the internal
recti leads to weakness of these muscles. It may also be produced by other ocular
conditions, especially in diplopia from any cause. Here the vertigo is characterised
by being relieved by shutting one or both eyes. So also is the dizziness felt on climb-
ing a height, or in a wide open space, as in the agoraphobia of neurasthenia.

(e) Gastbio Vebtiqo is a variety which has been described by several observers
{e.g., by Trousseau), but for my own part I believe many of such cases are of circu-
latory origin. The fact of the close relation between the taking of food and the
giddiness, to which some refer, is sufficiently explained by the effect of a full stomach
upon the abdominal sympathetic or mechanical impediment to the heart. Disorder
of the liver is also credited with producing giddiness.

(J) A Lartnqbal Vebtioo has been described in which the patient gets giddy, and
may fall on attempting to cough.

The Treatmenl of vertigo must be directed to the cause, but as a palliative measure
the, bromides are of great value.

Disordered SabjeotiTe Sensatioiis of many kinds may be complained ol in diseases
of the nervous system.

a. Subjective sensations referable to the extremities, such as numbness, tingling,
etc., which will be mentioned under peripheral neuritis and disorders of sensation.

6. Subjective sensations referable to the special senses, smell, sight, hearing, and
taste, which will be mentioned under diseases of the cranial nerves.

c. Subjective sensations referable to the mind, hallucinations, delusions, etc., which
are dealt with in mental disorders.

d. Subjective sensations which affect the equilibrium are mostly included under
the term vertigo or giddiness (vide stipra).

PART B, CLINICAL INVESTIGATION.

§ 512. The Method of Wr^mining a nerve case differs somewhat from
that in other departments of medicine, partly on account of the inaccessi-
bility of the nervous system to direct examination, and partly owing to
the widespread effects of its diseases. It is, however, not difficult pro-
vided the beginner adopts a fixed order of examination. It requires
more time, but if the reader studies carefully what follows, he should find
no more difficulty in diagnosing diseases of the nervous system than those
q{ the heart or stomach, especially if he remembers that there are two
'problems in the diagnosis of nervous cases, which should be solved in this
order : first, to localise the lesion (is it generalised, or in the brain, the
cord, or the nerves ?) ; and, secondly, to ascertain what is the nature
of the lesion. The following table represents a scheme which may
be adopted for a systematic and complete investigation, taking first
that nervous function to which the patient's symptoms are mainly
referable :

Firsty examine the leading symptom or sign.

Secondly y the history of present illness, the previous and family histories.

712 THE NERVOUS SYSTEM [ % 618

The History of the case is of considerable importance in diseases ol the nerrous
system, and must be patiently and thoroughly investigated.

The history of the present illness ne&ds most careful^inquiry. Many nervoas
S3rmptomB are vague, or what the patient regards as unimportant. Sometimes the
onset is acute, but far more frequently it is most insidious and chronic. Paraplegia
and many other diseases run a very prolonged and changing course, and the physician
who sees a case three or four years after its onset may be wholly without reliable data
on which to found a diagnosis as to the nature of the lesion, other than those which
the history reveals. The exact dates (1) of ceasing work, and (2) taking to bed are
most important.

The previous history may reveal lead or other metallic poisoning, gout, tuberculosis,
syphilis, or other predisposing causes of nervous affections. Alcohol and S3rphllis
play a prominent part in the etiology of nearly all diseases of the nervous system.
The toxins of diphtheria and influenza among the infective fevers seem to be the
most inimical to the nervous system. Traumatism, mental and emotional strains
often play a part in the etiology. The influence of sexual abuses is considerable
but is often, in my belief, exaggerated. Some diseases, like hysteria and migraine,
are recurrent throughout life, and the history of previous attacks is a most important
aid to their diagnosis.

In the family history a neuropathic diathesis may be revealed by ancestors and
relatives having suffered from some nervous disease. In a nervous family the in-
herited instability may take the following forms : epilepsy, hysteria, mental disease,
migraine, and other vaso-motor conditions. Consanguineous marriages intensify
this diathesis.

Thirdly, proceed to the examination of th<

I. General s3rmptoms and mental attitude ; the temperature in

certain cases ; pain ; any defect in the skull.
II. Muscular system — weakness, walk, spasm, tremor, atrophy.

III. The deep and superficial reflexes.

IV. Electrical reactions.

V. Special senses and cranial nerves.
VI. Cutaneous sensation.

VII. Organic reflexes ; trophoneuroses ; the sympathetic sjrstem and
the angioneuroses.

VIII. In certain cases the cerebro-spinal fluid should be examined.

§ 518. 1. General Symptoms. — The majority of cases met with in private
practice and out-patient work belong to the generalised neorotes, where
the s3rmptoms consist of vague pains or bodily discomfort, nervousness,
restlessness, insonmia, etc. In many of such cases an examination of all
the organs and Junctions of the body will frequently reveal some defect of
these organs or functions to which the nervous condition is secondary.
The neurologist needs to be a skilled general physician.

The mind of the patient plays a very important part in all disorders of
the nervous system. We have to judge how much of the malady exists
in the patient's mind, how far we can rely on his description of his
symptoms, even apart from any mental or moral alienation which may
exist. Careful observation during our investigation of his medical history
may teach us much concerning a patient's mental condition, and some of
the chief points to investigate are sleep, dreams, memory, intelligence,
reasoning power, decision, attention, moral and ethical standards, de-
liisions, hallucinations. In judging a person's mental condition or ability.

§ 614 ] THE MUSCULAR 8 Y8TKM 713

one must be a well-read man of the world first and a physician afterwards.
This was what Sydenham meant when he replied to a gentleman who
asked what books his son should read as a preparation for the medical
profession — " Let him read * Don Quixote ' ; that's a very good book."
Common sense and tact, as well as ability and experience, are indispensable*
It is, moreover, necessary to enter sjnnpathetically into the feelings and
thoughts, mode of life, and mental attitude of your patient before he will
favour you with his entire confidence.

Pyrexia is absent in chronic diseases of the nervous system. It ushers
in Infantile Paralysis, and attends Meningitis. In cerebral abscess
pyrexia may be absent, excepting just at the outset. Practically, per-
sistent fever in a case of nervous disease indicates some inflammation of
the cerebro-spinal meninges.

Pain and its method of investigation are mentioned under Neuralgia
(§ 604), and in various other parts of this work.

The investigation of the sknll is considered in §§ 13 and 624.

§ 514. The Mnscnlar Ssrstem gives some of the most reliable evidences
of disease of the nervous system. The muscles may be affected in four
ways —

(a) Weakness or paralysis.

(6) Alteration of gait, or inco-ordination.

(d) Atrophy.

There are two other points which are speciaUy related to muscular
defects — the condition of the deep reflexes, and the eleotrioal re-
actions of the muscles involved.

(a) Is there any loss of power ? Can the patient walk ? Can he sit

up in bed ? Can he move each of his limbs as a whole ? Is the motor

weakness localised to a few muscles ? These are all points to investigate.

The degree and exact position of the weakness (which enables us to localise

the lesion in the nervous system) should then be investigated. Paralysis

is a total, paresis a partial, loss of power. In the case of the handgrip

the degree of weakness can be measured by a dynamometer, but in other

instances we can only roughly estimate the degree of weakness of a muscle

or group of muscles by the strength of passive resistance on the part of

the operator required to prevent a certain movement.

HsMiFLEaiA is paralysis of one side of the body ; fabapleoia, paralysis of both
legs ; MONOPLBQIA, paralysis of one limb (crural of one leg, brachial of one arm) ;
DiPLBOiA, paralysis of both sides of the body ; brachial diplboia, paralysis of both
arms ; bifleoia facialis, of both sides of the face. In cases of apoplexy or coma it
is often difficult to test the presence of paralysis, but its existence on one side may be
indicated by a greater limpness on that side — the arm when^raised and allowed to
drop will fall inertly — or it can only with difficulty be raised because of the paralytic
rigidity on the paralysed side. Sometimes an individual muscle or a group o/ muscles
is affected, and a knowledge of the action of muscles enables us to decide which is
involved. Go patiently through the movements of a joint, or those performed by
individual muscles, offering passive resistance to each movement in turn ; this reveals
the position and the degree of the defect. The big joints are capable of six move-

714 THE NERVOUS SYSTEM [ § 614

ments — flexion, extension, adduction, abduction, rotation, and circumduction ; the
smaller joints only the first two or the first four. The action and nerve supply of
the various muscles are given under plexus and single nerve paralysis ({ 569).

(6) Is there any alteration of gait or inco-ordination ? Note should
always be made whether a patient can or cannot walk, and a patient
shoidd, if possible, be made to walk before us. The gait in locomotor
ataxy, paralysis agitans, spastic paraplegia, and many other affections,
b very characteristic (§ 577).

iNCO-OBDnvATiON is a defective oo-operation of the different muscles involved in
a particular movement of a limb, unaccompanied, it may be, by any loss of muscular
power. In the legs inco-ordination is apparent by an exaggeration of the normal
movements (as in locomotor ataxy), or an inability to balance while walking (ae in
cerebellar tumour). The patient may be asked to walk along the edge of the carpet.
If the patient is in bed ask him to follow your finger round in a circle with his big toe,
or to touch, with his eyes closed, the dorsum of one foot with the big toe of the other.
Another test is to ask him to stand with heels together and the eyes shut, and notice
if he stands steadily or sways about (Bombbbg's sign). A very delicate test of the
same kind is to ask him to balance himself on tiptoe, with knees bent and eyes closed.
To test the upper extremities ask him to thread a needle, or (with eyes shut) bring his
two forefingers tip to tip in front of him, or to touch the tip of his nose. Co-ordinated
muscular movement depends upon the integrity of the muscle sense, the vision, and
the cerebellar control. When the eyes are closed or bandaged, vision is eliminated.

Muscle sense is a term formerly employed to indicate the power by which the patient
appreciates or judges the state of contraction of a muscle. It includes the KinsBithetio
feme (or sense of muscular contraction) and the jointnenie. It is an extremely
delicate sense, for it is mainly by this sense of the ocular muscles that we judge
distance. In tabes dorsalis this sense is defective. It is tested in two ways : (i.)
The sense of judging weight is tested in the arm by placing objects of the same size
and configuration, but of different weights, in the patient's hand. A match-box
with coins, and one with cotton wool inside, or baUs of the same size but di£ferent
weights may be used, or objects can be placed in a handkerchief and slung on to the
hand or foot. Normally a healthy person can detect a difference of one-seventeenth
between two weights, (ii.) The sense oj position of a limb or joint-sense is tested by
bending a joint about in various positions, and finally asking the patient in what
position you have left the fingers or limb— bent or straight— or asking him to put
the other hand or leg into the same position. The operator must cease to touch the
skin, and the finger or toe must not be in contact with any other member or object,
otherwise the patient's tactile sense comes into play. Another rough test is to teU
the patient with his eyes closed to touch the tip of his nose with the tip of his first
finger.

(c) Is there any ^paam, tonic or clonic, or tremor ? if so, note its kind,
degree, and distribution. Tonic spasm or rigidity is a continuous muscular
contraction ; clonic spasm or tremor is an intermittent muscular contrac-
tion. Smaller, more rapid or vibratory movements are known as tremors.

A tonic rigidity is obvious on attempting to bend the limb ; it may be generalised,
as in the case of tetanus, or localised to the paralysed limbs in hemiplegia and para-
plegia (owing to descending sclerosis). Early and late rigidity are referred to under
hemiplegia.

Clonic spcisms and tremors can generally be rendered more obvious by the patient
holding up the affected member. Some tremors are only present when the affected
muscles are in action (intention tremor) — e,g., those of disseminated sclerosis.

Athetosis is a peculiar condition of slow mobile spasm intermediate between tonic
and clonic spasm.

Convulsions are violent clonic spasms. It is important to ascertain first the point
at which the convtdsions started or predominated, or whether they were generalised ;
secondly, whether the patient was unconscious or not ; thirdly, whether the fit was

§616] DEEP, SUPERFICIAL AND ORGANIC REFLEXES 715

preceded by a warning ; fourthly, what was his condition after the fit ; fifthly, whether
there was any involuntary evacuation of motions or urine, or biting of the tongue ;
sixthly, whether the patient has had any previous attacks of the same or a different
kind.

Hypertonia or hypertonioity is increase in the tone of all the muscles hardly amount-
ing to tonic spasm ; hypotonia is a diminution of the muscular tone. Kemig*8 sign,
which is found in 85 per cent, of cases of acute cerebro-spinal menginitis, is an evidence
of hypertonioity. It consists of a strong contraction of the hamstring muscles after
they have been stretched. To elicit it with the patient in the recumbent posture,
brin^ the thigh to a right angle with the abdomen ; then on trying to extend the leg
oi toe thigh strong contraction of the hamstrings prevents full extension.

((Q Is there any muscular atrophy ? Atrophy may be elicited roughly
by pinching the muscles and finding them flabby and wasted, or by the
measuring-tape. Finer defects of muscular nutrition can only be obtained
by electrical examination (§ 516).

Muscular atrophy arises from (1) disuse ; (2) diseases of the spinal cord which in-
volve the anterior horns ; (3) diseases of the peripheral nerves ; (4) diseases of the
muscles (myopathies) ; and (5) diseases of the joints.

§ 516. III. There are three kinds of Reflexes to be investigated — deep»
superficial, and organic.

(a) Are the deep reflexes altered ? When the tendon of a muscle that
has been put on the stretch is struck, the muscle immediately contracts
and produces a jerk of the limb. This is known as the deep or " tendon
reflex." To elicit the knee-jerk or patellar tendon reflex get the
patient, if possible, to sit on the edge of a bed, table, or chair, with the
legs hanging freely y or cross one leg over the other and let it hang as though
is not did belong to him. These positions slightly stretch the quadriceps
extensor and reflexly increase its tone. Now strike the patellar tendcm
sharply with the tip of the Angers, or the edge of a rubber-shod hammer
or stethoscope, and the leg will immediately jerk forwards from the
sudden contraction of the quadriceps. The patient's attention may be
engaged by conversation or by hooking the Angers of the two hands
tightly together, and trying to pull them apart ; this is caUed the " rein-
forcement" of the knee-jerk. An increase or diminution in the knee-
jerk may be conveniently indicated by k. j. + or - 1, 2, or 3. The strength
of the knee-jerk varies in health ; it is less marked in the young and in
the old. It is exaggerated in all upper motor neuron lesions ; it may
also be increased in hysterical and other functional neuro-muscular irrita-
bility. It is diminished or lost in lower motor neuron lesions or when-
ever the reflex arc b interrupted by disease, as in locomotor ataxy.

The knee-jerk is increased (k.j.+ ) (1) when the lateral columns are affected by
sclerosis, after cerebral or spinied lesions (sooner or later all upper neuron lesions are
so attended). (2) When there is increased irritability of some jMut of the reflex arc,
as in (i.) tetanns and strychnine poisoning, or (ii.) spinal meningitis. (3) When there
is defective inhibitory control from the higher centres, as in hysteria (strychninism
of Charcot), or in toz»mic states, such as phthisis, typhoid, or some cases of neuras-
thenia.

The knee-jerk is diminished (k.j.-) or absent (1) in all lesions of the lower motor
neuron, such as infantile paralysis and other diseases of the anterior horns, and peri-
pheral neuritis (alcoholic, diphtheritic, etc.). (2) In certain chronic spinal lesions,
notably tabes dorsalis, and in some cases of disseminated sclerosis when the grey

THE NERVOUS SYSTEM

[S515

matter is involved. (3) In certain acute lesions of the cord other than infantile
paralysis ; thus in myelitus affecting the lumbar enlargement, and in transvorsa
myelitis or other complete transverse lesions of the spinal cord, the knee-jerk at first
is generally, but not always, absent. (4) In primitive myopathies (idiopathic myo-
pathy and pseudo-hypertrophic paralysis), in proportion to the loss of mosciilAr
power. (5) In cerebellar tumour, especially in tumours of the lateral lobe. (6)
During coma, and also directly after the convulsive stage of epilepsy.

Most of the superficial tendons can be tested in the same way, though not with the
same facility, the points boing (1) to get the muscle to be tested relaxed by tho patient.
(2) gently stretch the muscle, and (3) strike its tendon. The tendo Achillis or anH^-
jerk may be tested while the patient is kneeling on a chair with the calf relaxed, the
foot being bent forwards, and the tendon struck by the operator. The triceps or
tlbouhjerk is elicited by hanging the patient's elbow over your wrist, and striking the
triceps tendon ; the supinator-jerk by tapping the tendon just above the styloid pro-
cess ; and the wrist-jerk by striking the extensor tendons when the hand is hangings
loosely. Tho jaw-jerk is not present in health ; when present it can be elicited by
placing one of your fingers firmly on the front of the chin, and tapping it with tho
other, as in percussion.

Ankle-clonus, or the clonus imparted to the calf muscles by stretch-
ing the tendo Achillis, is elicited by supporting the patient's knee with
one hand and suddenly dorsiflexing the foot with the other hand, gently
maintaining the pressure of your hand on the ball of the foot all the time.
It is present with organic diseases in the same circumstances as increased
knee-jerk and ankle-jerk — i.e., in ufper neuron lesions. Under the same
conditions knee-clonus may be obtained by placing one finger above the
patella, the patient being in a recumbent position, and percussing the
finger with the other hand.

The tendon reflexes are of use not only to detect which of those two
important groups of lesions is present — upper or lower motor-neuron
lesions — but also to ascertain approximately the level of the cord which
is involved, as may be seen from the table below.

Table showinq the Spinal Segment involved in the Deep

Reflexes.

Reflex.

K.-J.

Ankle-clonus.

Elbow-jerk.
Supinator-jerk.
Wrist- jerk.
Jaw-jerk.

Spinal Segment Involved,

Second and third L.

Third, fourth, and fifth

sacral.
Seventh cervical.
Fifth cervical.
Sixth cervical.
Motor nucleus of the fifth

cranial nerve.

Opposite Vertebral,
Spines of—

Tenth and eleventh D.

spines.
First L.

Fourth C. spine.
Third C. spine.
Fourth C. spine.

Kyotatio Initability consists of the too-ready contraction ol a muscle when its
muscular substance is struck. This is frequently seen in advanced phthisis, and
other exhaustive diseases — e,g., in percussing the chest. In tetany the condition is

§616] ELECTRICAL EXAMINATION OF THE MUSCLES 717

very marked, the facial muscles being thrown into contraction when struck or
Bcratohed.

(6) The Snperfloial Reflexef . — On stimulation of certain parts of the skin or mucous
membrane with a blunt pin or the top of a penholder, a contraction of certain associated
muscles takes place, as shown in table in § 558. It is a true reflex action, and can
only be obtained when the afferent and efferent paths and the corresponding grey
matter in the cord or brain are intact. The chief uso of the superficial reflexes in
medicine is to determine the locality of a disease in the spinal cord. The mode of
eliciting and situation of the ganglionic centre for the plantar, gluteal, cremasteric,
epigastric, abdominal, and interscapular reflexes are given in the table just referred
to. The conjunctival reflex, obtained by touching the conjunctiva, causes con-
traction of the orbicularis palpebrarum, and its ganglionic centres are situated in the
fifth nucleus (sensory) and the seventh nucleus (motor). The palate reflex, obtained
by touching the soft palate, leads to its elevation by the levator palati ; the afferent
nerve is the ninth, the efferent the accessory part of the eleventh (through the vagus).
The cutaneous reflexes vary considerably in different individuals. They are normally
more prompt in children than adults, and in women than men, and are difficult to
obtain when the skin is harsh and insensitive, as it usually is in the aged, or when
there is much subcutaneous fat.

Babinski^s Reflbx is a modification of the plantar superficial reflex. To elicit
it the patient should be in the recumbent posture, with the lower limb sUghtly flexed,
and the sole of the foot warm and dry. The sole is gently stroked upwards by the
finger-nail or a blunt pin. In health the big too and the other toes will become flexed
upon the solo ; this is the normal reaction. In Babinski's reflex there is extension of
the great toe followed by flexion of the other toes. The stroking should not be hard
enough to evoke dorsi flexion of the foot, as this obscures the big toe reflex. This
reaction is only met with in organic disease involving the lateral column. Babinski
found it was elicited best by stroking the outor side of the sole. In Junctional oases
the plantar reflex, if itwcan be elicited, gives a flexor response as in health (in functional
cases a diminution of the plantar reflexes with exaggerated knee-jerks is a characteristic
combination), and the same obtains in peripheral neuritis, poliomyelitis, tabes, and
even in intracranial tumours, provided the pyramidal tracts are not involved. In
infancy, before the ago of walking, an extensor (not a flexor) response is normal.

$ 616. Eleotrioal RxaminatJon of Mnsolef and the nerves which supply them is an
important aid in distinguishing lotoer from upper motor neuron lesions, and in detect-
ing the degree of disease or degeneration in a nerve or muscle.

The APPARATUS REQUIRED is not complcx, The chief requisite is a faradic coil,
because the first and most important point is to ascertain the degree of faradic con-
traction. A simple Ruhmkorff coil, of which the secondary coil slides on to the
primary, is needed. It is better if the wire of the former is not too thin, as it produces
unnecessary pain. A couple of moderate sized Leclanoh^ cells will drive it. Two
wires and three electrodes are requirod, one largo (measuring about 6 by 4 inches),
a round medium-sizod ono, and one small (about 1 inch in diameter). The two smaller
ones should be fitted with an interrupting handle.

A suitable galvanic battery is more expensive, for it requires at least twenty-four
small Leclanch^ cvlls (capable of giving about 35 to 40 volts), a collecting board and
reverser, with electrodes as before, and, to be complete, a galvanometer that has
been properly tested (Fig. 151). The constant current can be used from the main
with a suitable switchboard.

To test the faradic reaction place the large electrode in the patient *s hand, on the
hack of the neck, or some other indifferent position, and another electrode, connected
with the interrupting handle, over the motor point of the nerve or muscle to be tested.
If, as frequently happens, the current is too strong for the finer degrees of difference,
the operator should take the electrode in one or other of his hands, and apply his
well-wettsd finger to the well-wetted skin of the patient. A knowledge of the motor
points of nerve and muscles is not indispensable, for a great deal may be learned by
rubbing the medium-sized electrode with plenty of water well over the limb. The
motor point of a muscle is near the point of entry of its nerve ; that of a nerve is
generally near its most superficial part. The electrodes and the skin should be very

728 THE NERVOUS SYSTEM [ § 584

consists of a tenderness on pressure on either inguinal region, which pro-
duces an indescribable feeling rising up towards the heart and throat.
Pressure in this, the ** ovarian " region, may determine some kind of
attack. This phenomenon is in no way dependent on the ovary, but as

1 have elsewhere shown,i is specially related to the ilio-hypogastric and
ilio-ingumal nerves- Similar hypercBsthetic or hysterogenic zones may
exist elsewhere. (5) Patches of ancesthesia or hypermsthesia may exist
almost unknown to the patient. The anaesthesia may occupy one half of
the body and involve the special senses on that side.

Hysterical disorders may affect any part of the body, closely simulating
organic disease. These are described under their suitable sections, and a
brief summary only is given here. (1) Disorders of motion — paralysis
of the voluntary muscles, hemiplegia, monoplegia, parapl^ia, rarely if
ever paralysis of the face ; tremors and convulsions, tonic and clonic
spasm of one or several limbs, or involving the whole body. (2) The
involuntary muscles may also be affected by paralysis or spasm — adductor
spasm or paralysis of the vocal cords, aphonia, dyBphagia, hiccough,
cough, dyspncBa, borborygmi, phantom tumour, vomiting without nausea.
(3) Anaesthesia may affect one limb or half of the body ; hypersesthesia,
especially of the spine, and various neuralgiae are common. (4) Joint
affections, with pain and stiffness, may occur. (5) Hyperpyrexia is said
by some to occur, with or without local manifestations of hysteria. (H) The
special senses may be affected — amaurosis, hemianopsia, retraction of the
field of vision, deafness, disturbance of taste and smell. (7) Finally,
there may be mental disorder — ^trance, catalepsy, hallucinations and
delusions — especially after convulsive attacks.

The Diagnosis of hysteria from neurastheina has been considered in
§ 523. The salient features of hysteria are its limitation practically to
the female sex, the jMroxysmal occurrence of all it« symptoms, and a
previous history of similar symptoms. Ihe diagnosis of the numerous
hysterical phenomena will be dealt with under the various disorders which
they most resemble.

Prognosis. — The hysterical diathesis lasts throughout the lifetime of an
individual, modified from time to time by their state of health and sur-
rounding circumstances ; but once hysterical, always liable to develop
hysterical manifestations. The disease never terminates fatally of itself,
but it often renders the life of an individual a misery to herself and those
around her.

Etiology, — ^Hysteria is practically confined to the female sex ; it occa-
sionally presents itself in the male sex, but only to the extent of about

2 per cent. Heredity is a potent factor, and can be traced in at least
75 or 80 per cent. ; the influence is transmitted particularly through the
mother. In many cases there is a family history of one or other of the
diseases dealt with in this group (Group I.). Faulty education or a life
of self-indulgence, or any mode of existence which leads to introspection,

1 The Lancet, July 20, 1901, p. 122.

§ 626 ] H YPOCHONDRIASIS 729

a diminution or abolition of the control normally exercised by the will,
undoubtedly foster the evolution of the diathesis. Faulty hygienic and
physical development in childhood also favour the occurrence of hysterical
phenomena in after life. The favourite ages when evidences of the
hysterical diathesis are most manifest, and when the various phenomena
are most likely to supervene, are soon after the evolution and at the
involution of a woman's sexual life. The determining cause of all hysterical
manifestations is some emotional shock, trivial or severe. No anatomical
or histological lesions have yet been discovered.

Of recent years the psychic origin of hysterical disorders has been receiving much
attention. Janet defines hysteria as '* a form of mental depression characterised by
the retraction of the field of personal consciousness, and a tendency to the dissociation
and emancipation of the systems of ideas and functions that constitute personality."
Sudden emotion is the usual cause of this dissociation of the personality. Freud
believes that hysteria has its origin in a painful reminiscence which is forgotten by
the patient. Every painful repressed wish is converted into symbolic expression
which may be either psychic or somatic. Though the experience may have dis-
appeared from the conscious memory, it is preserved in the subconsoious mental life
of the patient, whence it can be elicited by the process of a painstaking psycho-
analysis, which in some cases may extend over several years. Once the buried reminis-
cence has been restored to the consciousness the physical manifestation disappears.
Freud's belief that hysteria always originates from painful experiences of a sexual
nature will not be so readily accepted.

Treatment. — ^Educational treatment is very important in these cases,
and as there are but few mothers possessing the combination of judgment,
firmness, tact, and kindness which is necessary in the treatment of these,
their own daughters, subjects of hysteria, should be entrusted to others.
Some regular occupation and interest in life is another means by which
the temperament may become controlled. Nothing to do or a frivolous
kind of existence is calculated to foster and develop the diathesis. Matri-
mony thus becomes a valuable adjuvant, because it gives to a young
woman occupation, interests, and responsibilities outside herself. Briquet^
showed conclusively that hysteria had no causal relation to ungratified
sexual passions. If the manifestations of the diathesis are sufficiently
pronounced, a course of treatment is indicated which comprises (1) removal
from the conditions under which the disease is fostered, (2) isolation from
sympathetic friends, (3) over-feeding with milk and other easily assimilable
foods, and (4) massage, which enables the patient to take and assimilate
more food. These four measures constitute the Charcot or Weir Mitchell
method of treatment. The treatment for the nervous attacks, when thev
arise, consists of the sudden application of cold water to the face, the
faradic battery to the limbs, and the internal administration of asafoetida,
valerian, and spirits of ether, or chloroform. A hypodermic injection of
apomorphine effectually terminates hysterical convulsions and other
violent seizures.

§ 526. Hypochondriasis is a morbid condition of the nervous system allied to
neurasthenia on the one hand, and melancholia on the other. It is an introspeotiye,

* " Traits Clinique et Th^rapeutique de THyst^rie/* par le Docteur Paul Briquet,
p. 20fi. Paris, BaUUfere et FUa. 1859.

720 THE NERVOUS SY8TEM [ §§ 517, 618

III. Severe diseases of the peripheral nerves :

1. Injury or pressure from tamours, persistent thickenings, bone disease,

operations, etc.

2. Rheumatic {e.g., in facial paralysis), and other toxic and infectious caoBes

— e.g., lead, alcohol, arsenic, diphtheria, and other infections.

The diagnosis of Myasthenia Gravis is facilitated by finding a characteristic faradio
reaction of exhaustion. The muscles at first contract normally to the faradic current,
but after a few contractions they get " tired," and will not contract even with the
strongest current. There is no alteration to galvanism.

In regard to prognosis, whenever faradio reaction is retained, even if only slight
with a very strong current, restoration of an injured or diseased nerve is possible ; if
it is quite lost for a few weeks restoration is still possible ; but if it remains totally
lost after several months there is but little prospect. Whenever an incomplete R.D.
is present the prospect of recovery may be considered even after notable atrophy.
Slight voluntary movement sometimes returns before the return of the electrical
reactions.

The slighter the lesion the less the alteration in electrical excitability. Slight
compression of a nerve enough to produce paralysis may produce but little alteration,
though in nearly all cases the faradic excitability is somewhat diminished.

§ 617. The investigation of the Special Senses and Cranial Nenres is
given in detail hereafter (§ 608). The points to investigate in order
summarily given are as follows (the Roman numeral refers to the crania]
nerve involved) :

Symptoms referable to the nose — smell (I.) ; discharge.

Symptoms referable to the eye — vision, ocular movements, pupils, and
fundi (n., m., IV., and VI.).

Taste, facial sensation, and mastication (V.).

Facial movements (VII.).

Hearing, tinnitus, or vertigo (VIII.).

Pharyngeal sensation, deglutition, muscles of palate and larjux ; also
sterno-mastoid and trapezius (IX., X., XI.).

Muscular power of tongue (XII.).

$ 618. Oomxnon Sensation. — Four kinds of common sensation are now recognised
by authors — ^touoh, pain, thermal sense, and pressure sense — and the two chief
points about each of these are whether it is increased or diminished, and what the
boundaries are of such alteration. To test a person's capacity to feel we must first
obtain his intelligent co-operation ; honesty and good- will are large factors in the
investigation. His eyes should be covered, and he should be instructed to say simply
" yes ** immediately he perceives any sensations. Corresponding points on the
opposite sides of the body should be tested if possible, and a negative test should be
applied from time to time. The sensibility dififers in different persons and in different
parts of the body. The student should first study § 502 and the remarks on Epioritic,
Protopathic, and Deep Sensibility.

(1) Cutaneous sensibility for totjch may be tested by the smooth head of a lady's
hat-pin, the finger, the comer of the handkerchief, or if desired to altogether eliminate
the sense of pressure, a small pad of cotton wool. For delicate investigations the
points of compasses are sometimes used. Ascertain whether (i.) sensation is loti
(anaesthesia) or increased (h3rperse8thesia), and (ii.) what are the boundaries of such loss
or increase {e.g., hemi-ansBsthesia or hemi-hypersBsthesia). Hysteria and locomotor
ataxy are frequent causes of altered sensation. In the former, spots of an an- or
hyper-ffisthesia may be present, and pressure on the tender spots (hysterogenic zones)
may produce fits, (iii.) Tactile sensation may be delayed, as in peripheral neuritis,
or (iv.) misplaced (allocheiria) as in tabes. Astereognosis is a want of recognition of
shapes of objects. Atopognosis is failure to locate a sensation properly. Both may
arise from gross lesions in the post -central gyrus (and therefore may be attended by

§686] ALOOUOLiaU 731

become slow, the memory, judgment, and will enfeebled, and later dementia
or some other form of insanity may ensue. Delirium tremens (see below)
supervenes from time to time, and sometimes epileptiform convulsions. The
digestive system is quite as commonly afiected. (i.) Chronic gastric catarrh,
attended by characteristic morning vomiting, is always present in spirit
drinkers, and gastric dilatation in beer drinkers, (ii.) Hepatic congestion
occurs in all cases, and cirrhosis (with or without fatty degeneration) in a
good number, but not in all. The heart dilates and undergoes fatty
degeneration, and the vesseb become thick and degenerated. The kidneys
become congested, enlarged, and later cirrhotic. The/iciea of the chronic
toper is characteristic — redness of the cheeks and nose, with oedema of
the conjunctiv».

Deliiiiim Tremens (deUriuin e fotu). — ^Dr. Francis Hare has conclusively
shown that this is due to the sudden reduction in the amount of circulating
alcohol in a chronic heavy drinker, and that it can always be prevented
by gradually tapering off the alcohol. Such a sudden reduction may have
been enfoiced or have resulted from vomiting. It is probable that the
delirium tremens which complicates operations or acute diseases such as
pneumonia is due to the deduction of the usual daily allowance of alcohol.
Incoherent mutterings or ravings, characterised by hallucinations of
vision (insects, spiders, or rats), accompanied by musctdar tremor, in-
tractable sleeplessness, and in bad cases two or three degrees of fever, are
the leading features of the malady, which usually runs its course in two to
five days.

The Diagnosis of chronic alcoholism is generally easy. The diagnosis
of delirium tremens is referred to in § 345. Care should be taken not to
overlook acute pnemnonia, particularly of the apex. The Prognosis of
delirium tremens for recovery is generally favourable if the temperature
is not much elevated and the strength of the patient can be maintained.

The Treatment of acute alcoholism consists of the administration of an
emetic, such as zinc sulphate, or apomorphine, \ grain, hypodermically,
and a large dose of calomel. A chronic alcoholic habit is rarely abandoned
after forty, and residence in a home is advisable in all confirmed cases, to
enable the patient to regain his self-control. In other cases much may be
done by careful domestic control and medical supervision. The gastric
catarrh must be treated, and the uncomfortable " sinking " feelings may
be much relieved by tincture of capsicum n|^v., sod. bic. gr. x., in an ounce
of peppermint or chloroform water. In acute and chronic alcoholism
one of the most distressing symptoms is insomnia, and it is difficult to treat.
In the acute form opium is said to be contra-indicated, and it is doubtful
if chloral or other hypnotics will shorten the attack. Digitalis in large
doses may be tried, but it will be found that large doses of bromides, and in
some cases opiiun, are generaUy successful. For dipsomaniacs (who have
periodic outbreaks) and those who are bom with an enfeebled nervous
system, little can be done unless they will surrender the control of their
lives to others. The great value of strychnine, atropin, and cinchona in

722 TBE NSnVOUS SYSTEM [ { fOA

convenient to adopt a regional method, beginning at the head and proceed-
ing downwards.

(a) Thb Head. — Inquire as to intelligence, sleep, pain, '^ attacks," oi
head sensations of any kind.

Eyes — ^vision, abnormality of pupils, squint, ptosis, nystagmus,
ophthalmoscopic examination.

Face — ^notice any defect of speech, tremor of the lips, or immo-
bility. Test the muscles by such directions as "Show me your
teeth," " Screw up your eyes," " Put out your tongue."

Hearing and other cranial nerves, as may be necessary, in numerical
order.
(6) Upper Limbs. — Examine the state of the muscles, and compare the
force of the grasp of the two sides.

Elicit any tfemor or involuntary movement by extending the hands
and fingers ; and direct the patient to touch the tip of his nose with
his forefinger, repeating the performance with eyes closed (ataxy).
Test the supinator and triceps reflexes,

Walking — ^Notice any peculiarity in the attitude or the gait ; can
the patient stand with heeb together and eyes closed (Romberg's
test)?

Examine the knee-jerks, test for ankle-doni^, etc.

(d) Test for abnormalities of common sensation (touch, pain, and
temperature).

Liquire as to state of the sphincters.

Remember, once more, that there are two steps in the diagnosis of

diseases of the nervous system, which, in order, are — first, localisatioii,

namely, what part of the nervous system is the seat of disease ? secondly,

what is the nature of the disease in that locality ?

II the sjrmptoms point to some ffeneralif ed nenroiii, turn first to Group L
(below).

If to defect of oonioioiunieM or the mind (Group II.) § 529

If there is definite pyrexia (Group III.) J 547

If the symptoms relate to the mnsoolar lyitem (Group IV.) —

Paralysis § 552

Inco-ordination or defect of gait $ 577

Rigidity $ 582

Tremor § 589

CSonvulsions § 597

Muscular atrophy § 600

If to some sensory or paintol disorder (Group V.) f 604

If to the fpecial fensef or cranial nerves (Group VI.) $ 608

If there is some deformity of the iknU (Group VII.) § 624

OROUP I. GENERALISED NEUROSES.

The word *' neurosis " connotes a functional disorder of the nervous
system, and by generalised neuroses are meant those which present
generalised symptoms. The symptoms presented in this group of dis*

628 ] NE U BAST HEN I A 723

orders are widespread and manifold, but nine- tenths of the patients complain
of nervousness. The remarkable resemblance of chronic alcoholism, mor-
phinism, and toxic neurasthenia in their clinical features to the other
members of this group, suggests that many of the cases here met with may
be dependent on some disorder of the blood.

I. Neurasthenia.
II. Hysteria.

III. Alcoholism.

IV. Morphinism and other drug habits.
V. H3rpochondriasi8.

VI. CoUapse.

§523. Neurasthenia is an irritable weakness of the nervous system,
which may arise from a great variety of causes, and may result in many
and various symptoms of nervous, mental, and bodily inefficiency.

The Symptoms are of a subjective order. The patient may come for
many different reasons : (1) A feeling of " weakness and nervousness " is
one of the most usual complaints, or he may state that he is easily tired,
easily startled, easily upset. The physical debility or disability is some-
times less marked than the mental, but it is often severe, and may be
sufficient to confine the patient to bed. Slight anaemia and loss of weight
may also be present. There are no physical signs unless the occasional
presence of exaggerated knee-jerks, retraction of the fields of vision, or
dilatation of the pupils may be so considered. It is convenient to describe
a cerebral, cerebro-spinal, and spinal type, according to the prevailing
symptoms. (2) Cerebral or mental symptoms are always present and
generally predominate. Everything the patient has to do is a trouble to
him, and a source of worry, and sometimes the simplest mental work,
such as adding up a colimin of figures, is impossible. The sleep is disturbed
by dreams, or there is insomnia, or " startings " in the sleep. All the
special senses are easily tired, and sometimes the patient is quite unable
to read. The pupils are usually dilated, and reaction to light and accom-
modation is sluggish. The memory and the power of concentrating
the attention are defective. Some patients are irritable, egotistical,
and exacting ; others gloomy and melancholic, constantly on the
grumble.

PsYCHASTHENiA has recently been described separately by Janet. It
frequently complicated neurasthenia, and has been described among the
mental characteristics of a variety of neurasthenia. It is now known
that it may appear apart from neurasthenia, but it may conveniently be
mentioned here. The condition appears in individuals who come of a
neurotic stock. They suffer from indecision and lack of will power, and
dominant ideas take possession of them from time to tune. These ideas
may be repulsive to them, yet they are powerless to dispel them. At the
same time they recognise that the ideas are groundless, for their reasoning
power is intact ; they do not have delusions or hallucinations.

Anxiety and morbid dread form a prominent feature, sometimes in-
definite— the fear of some unknown evil — sometimes definite, such as

724 THE NERVOUS SYSTEM [ §

agarophobia (fright when being in an open space), claustrophobia (fear
of going into churches or other buildings), monophobia (fear of being
alone), antheropophobia (dread of society or of people). Sometimes the
dreads take the form of paroxysmal panics or terrors, which pass oft as
suddenly as they come, and I have seen several of such cases pass on to
melancholia and dementia.^ There is no doubt that the miseries of
neurasthenia and of psychasthenia are very real, and not a few patients,
particularly cases of the gloomy type — those who go wearily on with their
work, saying but little of what they feel, who have probably never actually
threatened suicide — seek relief by terminating their lives. Other patients
drift into a chronic and incurable hypochondriasis. (3) Spinal and mus-
culo-sensory symptoms are also present in greater or less degree — ^restless-
ness and jerking of the limbs, weariness on the least exertion, vague pains
in the back and limbs, generalised tenderness or a hypersensitive condition
of the whole body, neuralgic pains and tender spots. Very generally there
is fine muscular tremor, but never localised paralysis or hemi-ansBsthesia,
as in hysteria, and never absent knee-jerks, as in tabes dorsalis. Absence
of knee-jerks excludes the diagnosis of neurasthenia. Spermatorrhoea,
nocturnal emissions, or the discharge of glairy fluid at the stool, and
sexual disability are met with. (4) There are generally symptoms which
may be aptly attributed to disturbance of the vaso-motor sympathetic
system — e.g., long-drawn sighs, causeless palpitation, attacks of flushing,
followed by shivering, a sensation of '^ pins and needles " in the limbs,
cold hands and feet. In psychasthenia the patient may have a dazed
feeling, as if the external world were imreal, or he may have attacks of
throbbing and flushing with a sense of terror of impending death. Palpi-
tation of the heart, giddiness, and faint feelings are also met with. It is
in the presence of these sympathetic symptoms and attacks that neuras-
thenia overlaps hysteria. (5) According to some authors, gastric symp-
toms form an essential part of the symptoms of neurasthenia, and this is
often, but not always, true. In a great many cases gastro-intestinal
disorder is the cause and accompaniment of neurasthenia, and in others
the asthenia of the nervous system has given rise to asthenia of the
stomach (gastric myasthenia).

In the Diagnosis the very vagueness of the symptoms is an aid. Neuras-
thenia is certainly not the same disease as hysteria (see table), nor is neuras-
thenia a new name for hysteria, as some suppose, though they overlap in
some respects. Hysterical phenomena are paroxysmal and recurrent,
with intervals of health, throughout life ; in neurasthenia the symptoms
are more or less continuous, occur almost equally in either sex, and are
liable to come on for the first time at any age.

The diagnosis from early Tabes Dorsalis and General Paralysis of the
Insane is sometimes extremely diflicult. In neurasthenia the knee-jerks
are never, in my experience, absent, and the typical Argyll-Robertson pupil

^ '* dinioal Leoturos on Neurasthenia/' 4th edition, J. H. Glaisher and Go., Londont
1908.

im]

NEURASTHENIA

726

never present. For the diagnosis of general paralysis of the insane, chief
reliance has to be placed on the typical articulation and the tremor of the
lips and tongue.

Table op Diagnosis.

Xeuraithenia.

Sex.
Age.

Canses.

Onset.

Mind.

Symptoms.

Resalt.

Botli sexes
equally.

Any age — young men
slightly predisposed.

Produced by overwork ;
gastoo-intestinal and
other causes of mal-
nutrition, toxasmia,
defective metabolism :
occasionally shock.

Starts gradually and
runs a fairly even
course.

Mental exhaustion and
hiabUity to think,
study, or do work ;
memory deficient;
intellect clouded for
business; always
tired ; temper irri-
table; depression
rather than sadness;
sometimes suicidal.

Chronic weakness and
nervousness; attacks
of vague sensations
about the head;
convulsions never ;
gastro-intestinal
trouble of some kind
in 75 per cent.

May last a long time,
but by appropriate
measures it is gradu-
ally OITRABLB.

almost

EytUria.

Female sex almost ex-
exclusively.

Definite manifestations
of some kind appear
for the first time
practically always
before twenty - five,
generally between fif-
teen and twenty.

Subjects of the hysteri-
cal diaUiesis are liable
to hysterical attacks
or symptoms tknugh-
out life. The deter-
mining cause of active
hysterical manifesta-
tions always an emo-
tional upset.

Onset sudden, gener-
ally with an attack
of some kind; all
phenomena vary from
hour to hour and day
today.

Wayward, impulsive,
and emotional ; fond
of gaiety and amuse-
ment ; usually joy-
ous, but laughter and
tears alternate with
great rapidity ; me-
mory and intellect
sometimes brilliant,
rarely deficient ; no
tendency to suicide.

Symptoms paroxys-
mal ; seixures of dif-
ferent kinds fre-
quent ; flush readily ;
attacks of globus and
syncope frequent;
convulsive attacks
in nearly half the
cases.

Active manifestations
disappear suddenly
and unexpectedly ;
very apt to recur,
and therefore only

TllCPORABILT OXTB-
ABLB.

HypochondfiatU,

Males chiefly affected.

Rare under thirty ; pre-
disposition from
thirty to fifty.

Solitary, sedentary life ;
prolonged gastro-in-
testinal troubles.

Starts gradually, and
runs an even and in-
tractable course of
indefinite duration.

Introspective habit;
observing accessible
organs and secre-
tions ; habitual sad-
ness ; no taste for
amusement : patient
tries an endless suc-
cession of remedies
and doctors ; alwajrs
striving for a cure.

No seixures of any
kind ; runs an even
course.

Once established hypo-
chondriasis is impos-
sible to eradicate :
progressive and nr-

OURABLB.

Prognosis. — Neurasthenia is essentially a chronic disease, and leads to a
^reat deal of misery, but is never fatal, excepting by suicide or complica-
ions. Some hold that neurasthenia is incurable. The author, however,

726 THE NERVOUS SYSTEM [§

believes it to be mostly curable, provided a careful investigation be made,
leading to the discovery of the cause or causes in operation. It may ran
on for years, especially if, as is so frequently the case, dyspepsia, colitis,
or some other chronic cause is in operation. Its prognosis depends chiefly
on (i.) its previous duration, and (ii.) the removability of the cause, and
(iii.) the age of the patient, being more favourable in younger persons.

Cau8<Uion, — Prior to 1898 neurasthenia was regarded as of purely nerve
origin — exhaustion and heredity playing the leading parts. In that year
the author showed that the disease was mostly dependent on a toxsemia
of some kind, and he classified the causes of neurasthenia into four groups,
compound causes being very frequently in operation : (1) ToxcBtnie causes,
which include dyspepsia, colitis, and other gastro-intestinal disorders,
such as chronic constipation, dilatation or kinlring of the colon, bad teeth
or pyorrhoea alveolaris, and various other infective foci. Abuse of alcohol,
morphia, or cocaine, and Graves' disease, may also be included here.

(2) Malnutrition causes, such as post-influenzal (a specially potent cause)
and other post-febrile and debilitating conditions, and deficient or defective
food. (3) Fatigue and over-functioning are factors which include pro-
longed overwork, worry, anxiety, deficient or defective sleep, severe pro-
longed pain and excessive venery. (4) Emotional and traumatic causes —
grief, shock (mental or bodily), railway and other accidents, in which the
neurasthenia need not supervene until a few weeks after the shock. Injury
may produce either " traumatic neurasthenia " or " railway spine " (see
Paraplegia). My statistics (loc, cit,) show that some underlying gastro-
intestinal cause is present in 75 per cent, of the cases. A hereditary
predisposition plays a part in the etiology — though not, in my belief, as
prominent a one as some hold — either by reason of a neuropathic predis-
position in the progenitors, or alcoholism or tuberculosis and other de-
bilitating agencies in the parents. In regard to age, none are exempt, but
neurasthenia is commoner in young and middle-aged adults than in ad-
vanced age or in children ; and 61 per cent, of the cases under my care
were males. A sedentary indoor life and the imhealthy atmosphere of
town life appear to predispose, and the rush and strain of modem civilisa-
tion favours the occurrence of the disease.

The Treatment resolves itself briefly into : (1) The alleviation of the
distressing symptoms as far as may be. Bromides are particularly useful
in this respect ; morphia and other sedatives require the greatest care.
Alcohol and tobacco should be avoided. (2) The removal of, or compensa-
tion for, the above causes. Dyspepsia is in evidence in by far the largest
number of neurasthenics in out-patient work, and it is surprising how
efficacious an alkaline gentian mixture is in the majority of cases. Aperients
and intestinal antiseptics are valuable. Regular outdoor exercise is useful.

(3) Nerve tonics with hygienic and educational measures conducted with
sympathy and encouragement will do much for those in whom hereditary
predisposition is strong. Among nerve tonics strychnine is very useful,
and arsenic, phosphorus, damiana, phosphates, glycerophosphates, malt.

I9SA] HYSTERIA 727

and cod-liver oil may be tried. Turkish and wann baths allay irritability.
Cold baths and judicious hydrotherapy, various forms of electricity, and a
regulated diet have all done service in these cases. (4) Complete physio-
logical rest of the nervous system is of the greatest value, but I cannot
recommend Weir Mitchell treatment — at least, in its complete form. Sea
voyages are beneficial. (5) In the most intractable cases operations on
the colon, as suggested by Mr. W. A. Lane, may be considered. (6) A
knowledge of psychotherapeutics is a useful addition to the physician's
armamentarium in the treatment, especially of the emotional varieties
of this disease and of psychasthenia.

§6&4« Hsrsteria is a word derived from votc/^ov, the womb, in the
mistaken belief which was prevalent in the Middle Ages that the disorder,
which is almost confined to the female sex, arose within that organ. The
disorder may be provisionally defined as a condition of instability of all
the emotional, vaso-motor, and all the reflex nervous functions, with a
tendency to the development from time to time throughout life of many
different forms of nervous seizure, and of various motor and sensorv
disorders closely resembling organic diseases of the nervous system, never
leading to a fatal issue. In the author's view, nearly all hysterical dis-
orders are dependent directly or indirectly on an inherent defect of the
sympathetic system.^

Symptoms. — There is no particular form of facies uniformly attaching
to hysteria, but the hysterical disposition i^ essentially one of unstable
equilibriimi of the emotional and other faculties of the mind. These
patients are easily aroused to violent expressions of feeling, hasty judg-
ments, impulsive actions, and to passionate exhibitions of various kinds.
There is hjrpersensitiveness to all forms of pain, and a tendency to neuralgia,
the favourite seats for which are just below the left breast, or on one side
of the head (clavus). The hysterical diathesis in an individual may also
be suspected by the presence or a history of any of the following symptoms,
which may with propriety be called the ** hysterical stigmata." * (1) Flush'
ings of the face and other parts with or without provocation. Sudden
pallor and other vaso-motor skin phenomena are also very frequent in
hysterical subjects.^ (2) Nervous attacks of some kind are sure to occur
in hysterical subjects sooner or later — " hysterics " (crying and laughing),
nervous faints, etc. They are specially apt to occur at the catamenial
period, or after some " contrariment " emotional disturbance. (3) " Olo-
hus " is a sensation as of a ball in the throat, or a sense of choking or
sulEocation. Flatulence is a frequent accompaniment of globus, and a
severe atack of globus with prostration is often terminated by copious
windy eructations. (4) " Ovarie " or the hysterical ovarian phenomenon,

^ ** Lectures on Hysteria and Allied Vaso-Motor Disorders/* Glaisher and Co.,
London, 1009.

^ A stigma etvmologioally signifies a permanent or abiding mark or sign by which
something may be recognised.

^ See a olinioal lecture on the " Skin Symptoms of Hysteria/* the Lancet, January 30 ,
1904 ; and " Lectures on Hysteria.**

728 THE NERVOUS SYSTEM [ § 604

consists of a tenderness on pressure on either inguinal region, which pro-
duces an indescribable feeling rising up towards the heart and throat.
Pressure in this, the " ovarian " region, may determine some kind of
attack. This phenomenon is in no way dependent on the ovary, but as

1 have elsewhere shown,^ is specially related to the ilio-hypogastric and
ilio-inguinal nerves. Similar hyperaesthetic or hysterogenic zones may
exist elsewhere. (5) Patches of ancBsthesia or hyfercBsthesia may exist
almost unknown to the patient. The anaesthesia may occupy one half of
the body and involve the special senses on that side.

Hysterical disorders may affect any part of the body, closely simulating
organic disease. These are described under their suitable sections, and a
brief summary only is given here. (1) Disorders of motion — paralysis
of the voluntary muscles, hemiplegia, monoplegia, parapl^ia, rarely if
ever paralysis of the face ; tremors and convulsions, tonic and clonio
spasm of one or several limbs, or involving the whole body. (2) The
involuntary muscles may also be affected by paralysis or spasm — adductor
spasm or paralysis of the vocal cords, aphonia, dysphagia, hiccough,
cough, dyspnoea, borborygmi, phantom tumour, vomiting without nausea.
(3) Anaesthesia may affect one limb or half of the body ; hyperaesthesia,
especiallv of the spine, and various neuralgiae are common. (4) Joint
affections, with pain and stiffness, may occur. (5) Hyperpyrexia is said
by some to occur, with or without local manifestations of hysteria. (6) The
special senses may be affected — ^amauroais, hemianopsia, retraction of the
field of vision, deafness, disturbance of taste and smell. (7) Finally,
there may be mental disorder — trance, catalepsy, hallucinations and
delusions — especially after convulsive attacks.

The Diagnosis of hysteria from neurastheina has been considered in
§ 523. The salient features of hysteria are its limitation practically to
the female sex, the paroxysmal occurrence of all itfl symptoms, and a
previous history of similar symptoms. The diagnosis of the numerous
hysterical phenomena will be dealt with under the various disorders which
they most resemble.

Prognosis, — The hysterical diathesis lasts throughout the lifetime of an
individual, modified from time to time by their state of health and sur-
rounding circumstances; but once hysterical, always liable to develop
hysterical manifestations. The disease never terminates fatally of itself,
but it often renders the life of an individual a misery to herself and those
around her.

Etiology, — ^Hysteria is practically confined to the female sex ; it occa-
sionally presents itself in the male sex, but only to the extent of about

1 The Lancet, July 20. 1901. p. 122.

§ 625 ] H 7P0CH0NDRIA8IS 729

Of recent years the psychic origin of hysterical disorders has been receiving much
attention. Janet defines hysteria as '* a form of mental depression characterised by
the retraction of the field of personal consciousness, and a tendency to the dissociation
and emancipation of the systems of ideas and functions that constitute personality.^'
Sudden emotion is the usual cause of this dissociation of the personality. Freud
believes that hysteria has its origin in a painful reminiscence which is forgotten by
the patient. Every painful repressed wish is converted into symbolic expression
which may be either psychic or somatic. Though the experience may have dis-
appeared from the conscious memory, it is preserved in the subconscious mental life
of the patient, whence it can be elicited by the process of a painstaking psycho-
analysis, which in some cases may extend over several years. Once the buricMi reminis-
cence has been restored to the consciousness the physical manifestation disappears.
Freud's belief that hysteria always originates from painful experiences of a sexual
nature will not be so readily accepted.

Treatment, — Educational treatment is very important in these cases,
and as there are but few mothers possessing the combination of judgment,
firmness, tact, and kindness which is necessary in the treatment of these,
their own daughters, subjects of hysteria, should be entrusted to others.
Some regular occupation and interest in life is another means by which
the temperament may become controlled. Nothing to do or a frivolous
kind of existence is calculated to foster and develop the diathesis. Matri-
mony thus becomes a valuable adjuvant, because it gives to a young
woman occupation, interests, and responsibilities outside herself. Briquet^
showed conclusively that hysteria had no causal relation to ungratified
sexual passions. If the manifestations of the diathesis are sufficiently
pronounced, a course of treatment is indicated which comprises (1) removal
from the conditions under which the disease is fostered, (2) isolation from
syinpabhetic friends, (3) over-feeding with milk and other easily assimilable
foods, and (4) massage, which enables the patient to take and assimilate
more food. These four measures constitute the Charcot or Weir Mitchell
method of treatment. The treatment for the nervous attacks, when thev
arise, consists of the sudden application of cold water to the face, the
faradic battery to the limbs, and the internal administration of asafoetida,
valerian, and spirits of ether, or chloroform. A hypodermic injection of
apomorphine effectually terminates hysterical convulsions and other
violent seizures.

§ 526. Hypochondriasis is a morbid condition of the nervous system allied to
neurasthenia on the one hand, and melancholia on the other. It is an introspective,

* " Traits Clinique et Th^rapeutique de THyst^rie," par le Docteur Paul Briquet,
p. 206. Paris, Baillifere et Fils, 1859.

730 THE NERVOUS SYSTEM § 629

melanoholio, or pessimistic habit of the mind, in which the patient believes, without
oause, that he is the subject of one or more serious bodily disorders. He is gloomy,
wrapped up in himself, but talkative ; a slight pain in the stomach is certainly oanoer ;
a alight palpitation is regarded as mortal cardiac disorder ; or the testidee hang too
low, and therefore he, will certainly become impotent for life. Yet, in spite of all,
he is not without hope, for he will spend his life taking physio and frequenting the oon-
salting-rooms of physicians, surgeons, and quacks — where he will argue " learnedly "
about his symptoms until the unhappy physician wishes he had not been bom. Nor
are these patiants suicidal — two points in which the condition differs from tmo
melancholia, which is a state of hopelessness and a tendency to self-destruction.

Diagnosis. — Hypochondriasis used to be regarded as the representative of hysteria
in the male sex, but it is in reality a very different malady (table in § 523). In the
former one does not meet with the *' attacks,** paralysis, and sensory alterations so
frequent in hysteria. Hypochondriasis bears a closer relation to neurtuthenia.

Causes. — Hypochondriasis is occasionally seen in the female, about the menopause,
but the patients are mostly men of middle age. It is rarely seen before puberty, or,
indeed, before thirty, and generally makes its first appearance between thirty and
forty. There is often a neurotic family history, and often one of insanity. Dyspepsuk,
hepatic, or intestinal disorder is always present, and may be looked upon as its most
frequent cause — a fact which is interesting when we remember the marked prostration
and depression which attend gastric and abdominal disorders. Flatulence is a
common symptom, and the stomach is often dilated. I am satisfied that many oases
which were formerly, and are still, regarded as hypochondriasis are in reidity intract-
able cases of neurasthenia, due to dilatation, kinking, stasis or sepsis of the osBoum
or colon.

Treatment is neither easy nor satisfactory. The dyspepsia should bo treated, and a
draught of amraoniated tincture of valerian, or pil. asaf. co., or some other anti-
spasmodic, taken occasionally for the flatulence. It gives relief, not only to the
flatulence but to other symptoms. The bowels should be carefully regulated and
otherwise treated. These means, with regular exercise, constant change, cheerful
society, help to break through the vicious attitude of the mind ; but complete recovery
is rare (see also Treatment of Neurasthenia, § 623).

§ 526. Alodholisiii or excessive indulgence in alcohol is met with clinically
in three forms : (1) Acute alcoholism, (2) chronic alcoholism, a phase of
which constitutes (3) delirium tremens.

Acute Alcoholism is due to an excessive quantity taken in a few hours.
It gives rise to mental disturbance, muscular inoo-ordination, and finally
narcosis with a marked lowering of the body temperature, and a heavy
alcoholic odour of the breath. The stupor of apoplexy, ursBmia, and other
causes of coma (§ 530), and the muttering delirium (§ 345) which occurs
in pneumonia and other diseases, are apt to be mistaken for dnmkenness
— a serious error which is best avoided by keejying a jxUient in bed under
observation, and suspending our judgment.

Chronio Alcoholism is due to the persistent imbibition of moderate doses
of alcohol over a long period of time. The effects are worse when taken
on an empty stomach or in the form of raw spirits. It acts as a tissue
poison on the nervous, muscular (voluntary and involuntary), and epithelial
elements, and hinders tissue oxidation, so leading to fatty degeneration.
. The Consequences and Symptoms in the earlier phases resemble neuras-
thenia in many respects, with special toxic effects added later. The
neuro-mttscular system early shows signs in (i.) the unsteadiness and tremor
of muscles, especially those of the hands, and in peripheral neuritis, of
which alcohol is the most frequent cause, (ii.) The mental processes

§ 526 ] ALCOHOLISM 731

become slow, the memory, judgment, and will enfeebled, and later dementia
or some other form of insanity may ensue. Delirium tremens (see below)
supervenes from time to time, and sometimes epileptiform convulsions. The
digestive system is quite as commonly affected, (i.) Chronic gastric catarrh,
attended by characteristic morning vomiting, is always present in spirit
drinkers, and gastric dilatation in beer drinkers, (ii.) Hepatic congestion
occurs in all cases, and cirrhosis (with or without fatty degeneration) in a
good number, but not in all. The heart dilates and undergoes fatty
degeneration, and the vessels become thick and degenerated. The kidneys
become congested, enlarged, and later cirrhotic. The fades of the chronic
toper is characteristic — redness of the cheeks and nose, with cedema of
the conjunctivse.

DeUxinm Tcemens {deUrium e potu), — ^Dr. Francis Hare has conclusively
shown that this is due to the sudden reduction in the amount of circulating
alcohol in a chronic heavy drinker, and that it can always be prevented
by gradually tapering off the alcohol. Such a sudden reduction may have
been enfoiced or have resulted from vomiting. It is probable that the
delirium tremens which complicates operations or acute diseases such as
pneumonia is due to the deduction of the usual daily allowance of alcohol.
Incoherent mutterings or ravings, characterised by hallucinations of
vision (insects, spiders, or rats), accompanied by muscular tremor, in-
tractable sleeplessness, and in bad cases two or three degrees of fever, are
the leading features of the malady, which usually runs its course in two to
five days.

The Diagnosis of chronic alcoholism is generally easy. The diagnosis
of delirium tremens is referred to in § 345. Care should be taken not to
overlook acute pneumonia, particularly of the apex. The Prognosis of
delirium tremens for recovery is generally favourable if the temperature
is not much elevated and the strength of the patient can be maintained.

The Treatment of acute alcoholism consists of the administration of an
emetic, such as zinc sulphate, or apomorphine, | grain, hypodermically,
and a large dose of calomel. A chronic alcoholic habit is rarely abandoned
after forty, and residence in a home is advisable in all confirmed cases, to
enable the patient to regain his self-control. In other cases much may be
done by careful domestic control and medical supervision. The gastric
catarrh must be treated, and the uncomfortable " sinking " feelings may
be much relieved by tincture of capsicum n\^v., sod. bic. gr. x., in an ounce
of peppermint or chloroform water. In acute and chronic alcoholism
one of the most distressing symptoms is insomnia, and it is difficult to treat.
In the acute form opium is said to be contra-indicated, and it is doubtful
if chloral or other hypnotics will shorten the attack. Digitalis in large
doses may be tried, but it will be f oimd that large doses of bromides, and in
some cases opium, are generally successful. For dipsomaniacs (who have
periodic outbreaks) and those who are bom with an enfeebled nervous
system, little can be done imless they will surrender the control of their
lives to others. The great value of strychnine, atropin, and cinchona in

732 THE NERVOUS SYSTEM [ § 627

the treatment of alcoholism and morphinism has no doubt been known
to several observers for some years, and I cannot speak too highly of them
as regards my own experience. Strychnine and atropin sulphates (hypo-
dermically), ^V grain and ^l^ grain respectively, may be given with cin-
chona bark (by the mouth) four times daily until the throat is dry and tiie
pupils dilated.^ No medical man should countenance a secret method of
cure. The moral influence of a well-ordered institution is a highly impor-
tant factor in the success of treatment.^

The treatment of delirium tremens calls in the first place for a reliable
attendant (perhaps two or three), for the patient may be violent in his
attempts to escape from his horrible visions, and artificial restraint may
be necessary. To procure sleep and maintain the strength by nouriah-
ment are the main indications. Large doses of bromide, and chloral (if
the pulse is not too weak) or hyoscine, j^jj grain, may be tried ; but, as a
rule, the malady nms it course unaffected by drugs. Graduated cold baths
and cold packs are often very efficacious in cases with pyrexia (§ 392).

§ -527. Morphinif m (Synonym : Morphia Habit, Morphlnomania) and other dmc
habiti. — Hypodermically, morphia in small doses is a nerre stimulant as well as a
hypnotic, and induces a feeling of contentment and well-being. But in the course of
twenty-four liours reaction and craving for more occur, particularly when pain is
present, and by degrees the dose has to be increased until in the course of a few months
twenty to one hundred times the normal dose is necessary to produce a feeling of
satisfaction, and can be easily tolerated. The only signs by which the morpkine
habituis can be detected are contracted pupils, pallor of the face, and the frequency
with which they withdraw to satisfy their craving — a difference being observed in
their depression before and their gaiety and brightness afterwards.

If such a patient is suddenly deprived of the drug, the following symptoms (which
I have been accustomed to call " amorphinism *') set in. The pulse, which was
previously normal, becomes rapid and of low tension, and the patient prostrate, suffer-
ing agonies from the tingling in the limbs, sweatings, sneezings, lachrymation, diarrhaoa,
vomiting, unoontrollable restlessness, faintings, sinkings in the pit of the stoniach,
extreme wakefulness, and a host of horrible and indescribable somatic sensations
resembling extreme neurasthenia.

Conseqtiences of the morphia habit. Enormous doses may be taken by gradual
increase ; one of the largest in my experience was 25 grains a day, reached after a habit
of only two years. At first the patient is always gay, and has great capacity for
mental and bodily endurance. But if the habit be continued, the character gradually
becomes altered, and various moral obliquities become manifest, llie patient
alienates his friends by his tempers and unreliability ; and, one by one, truth, reverence,
virtue, and honesty disappear. If there bo difficulty in procuring the drug, great
craftiness is exhibited, and cases are known of women previously of the highest charac-
ter selling their virtue and their husband's honour to procure it. In course of time
the mental powers gradually degenerate, and suicide is not infrequent in those who
desire but are unable to rid themselves of the thraldom. The body also suffers, and
the patients become pale, and generally emaciated. They get careless in the use of
their syringe, multiple abscesses form and death may result from septicemia. Fatty
degeneration of the viscera ensues, especially of the heart, as in the case of a girl aged
nineteen, which was reported in Paris some years ago. My own belief is that some
of the cases of sudden death reported as due to overdose of morphia might be shown
to be due to this condition.

1 Mr. S. B. Penn, BriL Med. Jaurn.. 1904, vol. i.. p. 1008 ; and Dr. C A. McBride.
Brit Med., Jaum., 1904, vol. i.. p. 1006.
^ *' Alcoholism and its Treatment/* Dr. Francis Hare, 1912.

§ 528 ] MORPHINISM-^COLLAPSE 738

Prognosis, — That the habit shortens life is certain, though it may go on for many
years. The danger of sudden death, due to causes just explained, or from an overdose,
is also consideFablc. The curability of a case of morphinism depends in my experience
on three points : The age of the patient, the duration of the habit, and the curability
>of the painful affection for which it was first contracted. The actual quantity per
diem which has been reached is of small account. A habit of 4 grains daily of ten
years* duration was more difiioult to cure than one of 22 grains of two years' duration.
If carcinoma or some other cause of an incurable and recurrent pain bo present, and
especially if the patient be aged, the tendency to relapse is great, and it may bo im-
possible to ease the pain in any other way.

Treatment, — (a) To break the habit the patient must place himself imder the absUule
control and guidance of a physician in whom he has confidence. Three methods are
advocated — sudden cessation, gradual redaction, and gradual reduction combined
with the substitution of solid opium or morphia by mouth or rectum. The first of
these should never be employed unless time is an object, for the suffering is very
great, and if the habit be of long duration, not without danger. In the third, which
is advocated by Dr. Oscar Jennings, of Paris, a definite scheme should be written out
by the physician, in which about double the quantity of opium, by mouth or rectum,
is aUowed to replace the gradual reduction in the morphia. Afterwards, when all
hypodermics have ceased, the opium internally can be gradually reduced without
much difficulty. The second method, gradual reduction, is the one which I have
found most successful. Cut down at once to one-half, then gradually reduce. There
should be no difficulty in reducing, by \ grain a day, down to 2 grains, after which the
reduction should continue in quantities less and less in a geometrical ratio by the
addition to the stock-bottle of sterilised water daily. The greatest difficulty is with
the last few grains, which patients may cling to for weeks or months. (6) Treatment
of the symptoms of amorphinism. Thz prostration and somatic sensations may be
partially relioved by moderate doses of alcohol, ammonia, and other stimulants, or by
strychnine, 4 minims hypodermically, and atropin, as recommended in § 526. It may
be necessary to give morphia. Digitalis and other drugs which aid the heart and
contract the vessels are useful. For the vomiting and diarrhoea bismuth is best, but
the diarrhoea should not be checked too much. Dionine in one case under my observa-
tion relieved the restlessness and craving. For the sleeplessness, chloral and other
hypnotics and analgesics may be tried, but none are of great use. After recovery
there are two tendencies: (1) towards relapse, and therefore the patient should be
kept under observation ; and (2) towards alcoholism, therefore great care is required
in the administration of stimulants.

The cocaine habit leads to many of the troubles of the morphia habit, only there
is a greater tendency to mental symptoms and mania. Morphia and cocaine is a
frequent combination, and in such case the cocaine may, with comparative ease, be
first withdrawn. Then the morphia reduction may be proceeded with as above
described.

The chloral habit is not so common nowadays as the preceding. The consequences
or symptoms consist of gastro-intestinal disturbance, lowered nutrition, pains, skin
eruptions, depression, and irritability, palpitation, and cardiac weakness. Sudden
death may occur from slight increase of the dose.

Snlphoiial, phenacetin, antipsrriii, and other tar products do not so readily engender
a craving, but when habitually used the patient cannot do without them, and in course
of time symptoms as in chloral hydrate arise.

§ 528. Collapse (or Shook) is an acute condition of extreme bodily weak-
ness, with exhaustion of the nervous system ; an extreme state of prostra-
tion. An attempt is sometimes made to distinguish shock and collapse,
but the two are clinically identical. The term '* shock " is applied to that
condition which follows any sudden mental or physical injury ; the term
** collapse " when it supervenes on some less sudden cause, such as cholera.
The condition in either case is a serious one. The pathology is still
obscure, but in effect there is paralysis, or more properly paresis, of all the

734 THE NERVOUS SYSTEM [ § 52S

muscular tissues of the body, voluntary and involuntary (muscles of the
limbs, of respiration, of the heart and arteries). The Symptoms may be
arranged under the following headings : (1) The skin is pale, cold, and
clammy (especially of the extremities) ; the surface temperature is 2° F.
or more under normal ; the pupils are dilated, and react slowly to light.
(2) The circulation and respiration are very feeble, the pulse being rapid
and scarcely perceptible. (3) Loss of voluntary movement (sometimes
restlessness and, in cases of profuse haemorrhage, convulsions). The mind
is apathetic, but the intellect is clear. The urine and other secretions are
diminished or suppressed. The patient may die, or may pass into a
reaction stage, with slight pyrexia.

Diagnosis, — In coma the mind is completely obscured, and the respira-
tion laboured and stertorous. Except the functions of organic life, all is
in abeyance. In syncope consciousness is generally lost, and the condition
of prostration is more transient.

The Calces of collapse may be divided into those of sudden and those
of gradual onset. When the condition is of sudden onset after injoiy
or emotion, it is usually described as shock.

(a) Of sudden onset : (1) An overdose of chloroform or ether. (2) Surgical
operations or severe injury. A vigorous man suffers more from operation
than an old man or one who has been in bed for some time previously.
Blows on the abdomen or extensive bums are always attended by more
or less collapse. A relatively slight injury to a very sensitive part, such
as the testicle, may produce collapse. (3) Severe and sudden emotions
(terror or grief), or acute pain coming on suddenly, such as biliary or
renal colic. (4) Poisoning by the narcotico-irritants (oxalic acid, carbolic
acid, phosphorus, etc.) and by the asthenic poisons (hydrocyanic acid,
aconite, digitalis, tobacco, veratria). A history in these cases may be
absent. Ptomaine poisoning from tinned meats, etc. , is attended by profuse
diarrhoea. In cases of anaphylaxis (§ 388) collapse may occur. (5) Profuse
haemorrhage or diarrhoea, as in post-partum haemorrhage and cholera. (6) In-
testinal obstruction. (7) Perforation of some part of the alimentary canal,
with extravasation of its contents intot he peritoneum. (8) Rupture of an
abdominal cyst or of an abdominal or thoracic organ. (9) Pulmonary or
other embolism. (10) Heat exhaustion after exposure to a very hot sun.

(6) Of gradual onset : (1) Privation and exposure combined. (2) Profuse
diarrhoea, such as usually teiminates lardaceous disease. (3) Peritonitis
and other abdominal inflammation. (4) The asthenic types of fever, such
as may attend enteric and yellow fever. (5) At the termination of many
diseases described in the chapter on Debility.

When a patient is found in a state of collapse or shock, the physician
has to diagnose the cause of the condition. After applying restoratives
he should inquire, first, whether there is a history of injury or emotional
disturbance, haemorrhage, etc. ; secondl}', ask if the patient was in good
health up to the time of onset of the condition of prostration, so as to ex-
clude group b ; thirdly, inquire what food the patient has recently taken,

J 62d ] SUDDEN AND TRANSIENT UNOONSOIOUSNESS ^S^

and remember the possibility of poison ; fourtbly, examine all the viscera,
especially the heart and abdominal organs, beginning at the part which is
or has been the seat of pain.

The immediate Treatment consists in applying warmth to the body by
means of hot bottles and warm blankets. The head should be lowered,
the feet raised, especially in cases following external hsemorrhage. Stimu*
lants, alcohol or anmionia, may be given by the mouth if the patient can
take them. Hypodermics of ether (ll\20 to 60 every half -hour) or liq.
strych. (n^lO) or brandy should be given. Pituitary extract may be
administered hypodermically. Normal saline solution may be adminis-
tered subcutaneously (§ 406) in cases where there has been profuse hemor-
rhage or diarrhoea, and in many other cases of collapse. It may also be
administered per rectum.

OBOUP 11. MENTAL SYMPTOMS.

Disorders of consciousness and of the mind form a very large group.
There are not many serious disorders of the nervous system in which
mental symptoms do not appear sooner or later ; and that complex organ,
the mind, has also disorders peculiar to itself. These are generally
omitted from textbooks on medicine, but the scheme of this work would
not be complete without a brief epitome of the more important.

It will be found convenient to deal with mental symptoms imder four
headings :

(a) Sudden interruptions of consciousness — dighi and transient, such as

petit mal ; or severe, and prolonged, such as coma • • • §§ 520 and 530

(/3) Partial mental and " one faculty " defects, such as speech defects,

or loss of memory § 533

(7) Acute perversions of the mind, such as delirium and mania . . § 536

(^) Chronic perversions of the mind in adults, adolescents, and children,

such as melancholia, dementia, and various special types . . § 537 et aeq.

The 'patient complains of sudden transient attacks of unconscioiisness.
The case is probably one of Syncope or Epilepsy Minor.

§ 529. Sadden, usually brief and transient unconsciousness. — The patient
comes, perhaps, complaining of " attacks," " sensations," *' faints,"
" dizziness in the head," or " interruptions of thought." You have only
the patient's account to guide you, and it may be a little difficult to
diagnose the condition, but it is probably Syncope, Epilepsy Minob,
Arterial (or senile) Vertigo, or some cases op Aural Vertigo.

It is necessary, first, to ascertain definitely whether the patient was
really imconscious : Did he know who was beside him, or hear when they
spoke to him, and did he fall down ? Secondly, the age and sex of the
patient — epilepsy appears for the first time between ten and thirty;
hysterical faints are almost always confined to young females. Thirdly,
the history of previous attacks.

I. Syncope is a loss of consciousness more or less complete, generally
of short duration, due to cardio-vascular failure of functional or organic

736 THE NEBV0U8 SYSTEM [ §

origin. It does not generally last longer than a few minutes, though
the duration and intensity vary considerably. Before the attack the
patient is pale, sometimes a useful warning. The process of going off
is accompanied by a disagreeable "swinmiing ia the head," which has
some resemblance to vertigo, or by an indescribable sinking feeling in the
-region of the stomach. The process of recovery is more gradual than in
petit mal. The diagnosis of cardiac syncope from nervous faints (of vaso-
motor origin), and these from petit mal, and their causes and treatment,
have been given in § 24, p. 35. Many considerations seem to point to the
probability that the essential cause of hysterical faints is an instability
of the abdominal sympathetic.^ We know that the blood-pressure in the
cerebral arteries is largely, if not entirely, regulated by the amount of blood
in the splanchnic area, being high when the latter is relatively empty of
blood, and low when it is relatively full.

II. Eidlepsy IGnor (Synonyms : Petit Mal, Epileptic Vertigo). — There
are two varieties of idiopathic epilepsy, E. major (§ 598), consisting of
unconsciousness with convulsions, and E. minor (petit mal), unconscious-
ness without convulsions. They sometimes alternate in the same individual.
There are many degrees, shading from one to the other, and few dispute
the identity of the two maladies. Only one circumstance can be seriously
urged in this direction — namely, that amyl nitrite will often stop an attack
of major, but increases the severity of an attack of minor, epilepsy.
Epilepsy minor may be defined as a momentary or brief loss of conscious-
ness, preceded — in about half the cases — by an aura or warning, un-
attended by convulsions, and often without falling, not followed by the
stage of stupor, and the whole lasting rarely more than half a minute to a
minute. In the attacks now under consideration, it may be that the
patient only pauses in a conversation, or there is only a vacant look, a
fixity of gaze, dilated pupils, or momentary pallor of the face, which none
but a close observer would notice. More usually, however, the patient
— ^who generally refers to these attacks as "sensations" — feels giddy
and loses his equilibrium for a few moments. The chief point of difierence
between nervous faints (§ 24) and minor epilepsy is that in the former
there may be no definite loss of consciousness, although the patient falls,
whereas in the latter a definite brief loss of consciousness is the invariable
characteristic, and the patient may not necessarily fall down. The absence
ef any apparent rotation of objects helps us to distinguish epilepsy minor
from vertigo ; and its appearance always for the first time in the earlier
decades of life distinguishes it from " senile syncope." Some say that
petit mal is more likely to result in insanity than grand mal. The Treat-
ment is on the same lines as that of epilepsy major (§ 598).

Masked Epilepsy is a still more incomplete form of epileptic attack, in which
the patient, though unconscious, continues to perform automatically various acts
during the seizure. Thus, a shoemaker under my care would continue his sewing ;

1 ** Clinioal Lecture on Hysterical Attacks,** the Lancet, July 20, 1901 ; and '* Lec-
tures on Hysteria,** Glaisher and Co., London, 1909.

§ 521ki ] SUDDEN AND TRANSIENT UNCONSCIOUSNESS 737

and Trousseau mentions a skilled violinist who continued to play with precision.
He also mentions a judge who used to leave the benoh during an attack of masked
epilepsy, micturate in a comer of his robing-room, and return to the Benoh again
without a return of oonsoiousness. The criminal records show that homicide may
be performed during these attacks.

III. Senile Syncope; Senile or Arterial Vertigo; Apopleotttorm Attockf.— Under
these teims may be included various attacks attended by unconsciousness, varying
in degree from a transient interruption of thought to a severe loss of consciousness.
Those who have much to do with old people are aware that brief losses of conscious-
ness are extremely frequent among them. Sometimes it amounts to nothing more
than a momentary confusion of thought. They were variously described by my old
patients in the Paddington Workhouse as *' dizziness*' or ''giddy faints.'* They
often give rise to a momentary reeling if they happened to be walking at the time.
But sometimes it is a definite unconsciousness, lasting one or two minutes, or longer,
in which they fall unless they lean against or catch hold of something. Every grada-
tion is met with between these attacks and a severe syncopal or apoplectic seizure.
These attacks are generally associated with arterial hypermyotrophy^ or some form
of arterial degeneration disease, especially when this is combined with cardiac failure.
In a few instances of the severer form of attack there were definite evidences after
death of minute softenings or hsBmorrhagcs of various dates, sometimes in considerable
numbers, with which the attacks were undoubtedly connected.

IV. Aural Vertigo (§§ 51 1 and 618). — Patients often speak of attacks of aural vertigo
as '' faints,*' though they are not usually attended by unconsciousness. It is not,
however, sufficiently recognised that severe attacks of aural vertigo may be attended
by complete loss of consciousness of some duration, and that such attacks may bo
connected with middle-ear catarrh as well as lesions of the inner ear. The attacks
in Meniere's disease are often so attended.

One of the most severe cases of paroxysmal vertigo with unconsciousness, due to
middle-ear catarrh, which I have met with occurred in G. G. B., set. thirty -eight, a
cattle dealer, who consulted me in February, 1896, for severe attacks of giddiness,
which he had had for two and a half years. The giddiness would come on suddenly,
without warning, '* like a windmill in the head," and '' things went all round " ; some-
times he became unconscious and fell down, unless near something to catch hold of ;
sometimes they were followed by nausea or vomiting. He had lately had two or
three a week, and since August, 1894, he had had to give up work. In one very bad
attack he became quite imoonscious for some time, And fell out of his cart. Six months
before the vertigo had come on — January, 1893— his hearing had gradually become
defective, and ever since then he had had a sensation as of a '' kettle singing in his
head." On examination, I found his hearing to be about half normal, but the peros-
seous hearing was good. All his symptoms were attributable to middle-ear catarrh.
After six mouths' pharyngeal and aural treatment under Dr. Bolton Tomson (of
Luton, Beds), his hearing was quite restored, and he was able to leave off the bromides
without a return of any of his troublesome and dangerous attacks.

§ 629a. V. Meniere's Disease (or Labyrinthine Vertigo) is a disease supervening
suddenly, with an apoplectiform attack, with unconsciousness, followed by rtnjurrent
attacks of paroxysmal vertigo, associated with nerve deafness due to hiemorrhago
into the vestibule or semi-circular canals. The term is sometimes applied to any
form of vertigo associated with deafness, but this does not tally with Meniere's original
description,^ and the name is better exclusively reserved for vertiginous attacks
attended by loss of consciousness, and associated with deafness.

There are four classical symptoms : (i.) The vertigo is always in paroxysms in
which, after the first attack, consciousness is retained, though the patient may fall,
owing to the disturbance of equilibrium. Irritation of the left semi-circular canals
usually produces a sense of rotation from left to right ; destruction the reverse,
(ii.) The attacks are commonly attended by nausea, or even vomiting, (iii.) There

^ Trans. Path. Soc., Lond., 1904.

^ It seems that all Meniere's original cases came on in an apoplectiform manner.
Gazette Mtdicale, 1861.

738 THE NERVOUS SYSTEM [ f

is deafness in the great majority of oases, on one or both sides, the patient being
unable to hear a tuning-fork plaoed on the teeth or the head (perosseous — i.e., nenre
deafness) ; and (iv.) tinnitus, or buzzing in the ears. In characteristio oaaes of
Meniere's disease these four symptoms supervene suddenly with an apopleotifonn
attack (accompanied by transient loss of consciousness), which has been shown to be
due to hnmorrhage into the labyrinth; (i.) and (ii.) afterwards become paroxysmal,
(iii.) and (iv.) more or less permanent. Kiiapp has observed that the hearing is im-
paired at first only for the higher and lower octaves ; and Charcot states that some
patients have the vertigo and buzzing only while the deafness is partial, disappearing
when this becomes totaL This is probably diagnostic of labyrinthine as diHtingnished
from central vertigo.

In regard to Treatmenlt the disease is undoubtedly very intractable, if not incurable,
and our efforts should be directed mainly to the circulatory system, so as to regulate
it and avoid a repetition of hemorrhage. The symptoms may be relieved by bromides
and other sedatives. Charcot recommends 5 grains of quinine thrice daily, and he
mentions one case which was cured by this means. Trinitrin often relieves the
symptoms for a time.

The patient is attacked with oomplete nnoonsoionsness, suddenly super-
vening and more or less frclonged. The case is one of apoplectic or other
form of Coma.

§ 580. Coma is a condition of loss of consciousness coming on more or
less suddenly, in which, in its complete form, all signs of vitality, excepting
those of organic life, are suppressed. The patient is deprived of all power
of movement and sensation. He is neither able to hear nor to imderstand
an order to put out his tongue shouted into his ear. The limbs fall help-
lessly into any position. The eyelids are closed, and the conjunctival
reflexes absent. The respiration is slow and stertorous, owing to the
flapping of the palate and the falling back of the tongue on to the posterior
wall of the pharynx. The pulse and the respiration are the only signs of
life. The temperature is — ^at any rate, at first — normal or sub-normal.
The typhoid state (§ 346) is a term applied to the comatose condition which
supervenes in certain fevers, and may be recognised by the presence of
pyrexia, the history, and the muttering delirium. Syncope is readily
distinguished from coma by the unconsciousness being much less in degree
and much more transient. The following is a list of the possible causes of
coma :

I. Head injury.
IJ. Apoplexy and other vascular lesions.

III. Other gross and functional cerebral lesions.

IV. AlcohoL
v. Opium.

VI. Urnmia.
VII. Diabetes.
VIII. Hepatic Diseases.
IX. Heatstroke.
X. Addi8on*s disease, Kayuaud^s disease, and other rare conditiooii.
Coma in children arises under somewhat different conditions (§ 532).
The CLINIGAX. INVESTIGATION of ooma is of the highest importance, as it is an
emergency of the gravest significance. When called to such a patient, whom one sees,
perhaps, for the first time, the question as to the cause is one of the most difficult
that we have to solve. The commonest causes of 8uch a condition are drink, cerebral
apoplexy, head injury, opium poisoning, and uraemia, and the prognosis and treatment
differ in these several conditions. Your mode of procedure should be as follows :

§ 680 ] OOMA 739

(1) Examine the head (and other parts) oarefally, to see if there be any signs of injury,
and if the ease be a medioo-legal one, make a precise written note on this point. If
there be evidence of an injury, the question of whether the injury has caused the
coma or whether it occurred after the patient was seized, should be borne in mind.

(2) Note the odour of ihe hreeUh, If this be alcoholic, it does not follow that the con-
dition is due to drink, for stimulants are frequently given by the friends to restore
the patient during such an attack. Note also whether the breath has the sweet
odour of diabetes. (3) Observe most particularly the state of each pupil and the
conjunctival reflex. Both pupils are much contracted in opium poisoning and
hsBmorrhage into the pons. Hsemorrhage into other and commoner situations within
the cranium usually causes inequality or dilatation of both pupils. In the other
causes of coma they are usually both dilated. (4) Ascertain whether any paralysis
of the limbs is present, or whether the face is drawn to one side. This may be a little
difficult, but usually in apoplexy the paralysed leg and arm of one side of the body,
opposite to that of the lesion, are very rigid or very flaccid as compared with the other
side, and by raising the limbs and allowing them to fall it will easily be found whether
one side is more rigid or more flaccid than the other. In nearly all cases due to gross
cerebral lesion (tumour, abscess, meningitis, etc.), one side is weaker than the other.
(5) Count the pulse, examine the arteries, and auscultate the Jieart. High arterial
tension suggests uraemia, apoplexy, or lead poisoning ; great slowness suggests tumours
and opium poisoning ; a presystolic murmur suggests cerebral embolism. (6) Count
and observe the respirations. A stertorous or snoring quality is simply an indication
of the profundity of the coma, being due to paralysis of the tongue and palate. The
respirations are very slow in opium poisoning. In grave cases of apoplexy and uraemia
the respiration assumes a Cheyne-Stokes character. (7) Take the temperature. It is
often very low in uraemia and in opium poisoning, sometimes a little lowered in
apoplexy and still more in drink. There is sometimes a tendency for it to run up after
an attack of apoplexy, and this is of very serious import. (8) Procure (by catheter
if necessary) and examine some of the urine. The absence of albumen is against
renal disease ; a small amount of albumen does not help one much to distinguish
between apoplexy and uraemia. In diabetic urine we find sugar ; in opium poisoning
morphia. Atropine and other vegetable alkaloids are also excreted by the urine.
(9) Observe the age. Coma in childhood is almost confined to post-epileptic coma,
meningitis, cerebral tumour, or sinus thrombosis ; about middle age cerebral haemor-
rhage is to be suspected. (10) Inquire into the history — whether the attack came on
suddenly in apparent health or after some previous indisposition. Coma sometimes
arises in the course of a disease, the history of which is readily revealed by inquiry,
such, for instance, as epilepsy. But, on the other hand, the patient's friends may have
been quite unaware of the existence of any disease, such, for instance, as diabetes,
contracted granular kidney, or cerebral tumour in the frontal region. The coma is
rarely preceded by convulsions in cases of opium and lead poisoning, diabetes, per-
nicious anaemia, deep-seated tumour, or abscess or injury. On the other hand, con-
vulsions usually precede the coma in hepatic and uraemic poisoning, general paralysis
of the insane, and tumours near the motor area of the brain.

The commonest causes of coma in everyday practice are drink, intra-
cranial hsemorrhage (with or without injury), opium poisoning, and urcemia
(see table on following page).

I. Head Injuries may produce either concussion (bruising) or com-
pression of the brain, the symptoms of which difEer more in degree than
in kind (table, p. 740). Injury may also be accompanied by conjunctival
haemorrhage, paralysis of the cranial nerves, and inequality of the pupiJs.
Bleeding from the ear and sub-conjunctival ecchymosis do not necessarily
(though usually) indicate fracture of the base. Injury to the head may
produce compression of the brain, and therefore coma, in four ways :
(1) Fracture of the skull, with depression ; (2) haemorrhage into or upon
the brain — in both of which the coma comes on immediately after the

740

THE NERVOUS SYSTEM

[im

Table of Diagnosis of Coma due to Drink, Apoplexy, Opium

Poisoning, and Uremia.

Drink.

Apoplexy
or Fractuie
with
CompresBion.

Opium
PoiBoning.

Ursemia.

Pupils (P.)

and

Conjunctival

Reflex (C. R.).

P. equal,

normal, or

dilated.

C. R. present.

P. usually

dilated and

unequal.

C. R. lott.

P. very
contraeUd and

equal.
C. R. usually

present.

P. normal or
diUted.

C. R. usually
present.

Pulse and
Respiration

iR-h

Pulse rapid

and strong^

then weak.

R. normal or

snoring.

Paralysis.

Depth of
Coma.

None, but Can he roused.
inco-ordination

if able to
walk or move.

Pulse gene-
rally full and

bounding.
R. stertorous ;

may be
Cheyne-Stokes.

Pulse and R.

both very

slow.

R. stertorous.

Hemipleffie

rigidity or

flaccidity and

often facial

paralysis.

General
weakness.

Cannot be
roused.

Pulse slow

and arterial

tension high.

R. sighing,

and may be

Cheyne-Stokes.

None.

Can
sometimes be
roused.

Cannot be
roused.

Course.

Progreasivo

recovery

in twelve

hoars.

Statkmary.

Progressive
towards death

or recovery

in ten to

twelve boors.

Coma

alternates with

convulsions.

injury ; (3) the effusion of inflammatory products, when the coma comes
on after an interval of a few days ; and (4) abscess, when coma comes on
aft^r a week or two at least.

Table of Symptoms op Concussion and Compression.

Concussion of the Brain.

Symptoms. — As in shock {q.v.), plus
sudden unoonsoiousness, but patient
can bo roused in most cases.

Pupils. — Equal, dilated, sluggish re-
action to light.

Jiespiration.--ShaXLow, slow, sometimes
sighing.

Motor System. — Muscles relaxed, but
no absolute paralysis.

JUcMer. — ^Froquent micturition.

Compression of the Brain.

Completely unconscious ; cannot be
roused.

Immobile, often unequal, at first con-
tracted, later on dilated.
Slow, stertorous, sometimes irregular.

Paralysis ; cheeks blown out with ex-
piration ; often rigidity on one side
of the body.

Retention till overflow with ** ftJse **
incontinence.

NoTS. — ^There is considerable difficulty of diagnosing whether a case has aUght
compression or a very grave degree of concussion.

§ 531. II. Apoplexy (a " stroke ") is a term which may be conveniently
retained to indicate a sudden unconsciousness due to a vascular lesion
within the skull. There are three kinds of such vascular lesions — luemor-

§681] APOPLEXY 741

rhage, embolism, and thrombosis. The older authors used to state that
hcBmorrhage from the rupture of a cerebral artery could be distinguished
from simple embolism or thrombosis by the occurrence of loss of conscious-
ness (sometimes accompanied by convulsions) in the former, and not
in the latter. But further experience has shown that this distinction
is only a matter of degree ; profound coma may sometimes arise from the
embolic blocking of a moderately large artery, or from thrombosis ; while,
on the other hand, slight haemorrhage supervening gradually may be
unattended by loss of consciousness. The extent and the suddenness of
the vascular lesion, rather than its nature, determine the presence of
coma.

Symptoms of Oerebral Hcemorrhage, — A prodromal stage or warning in
the form of headache or vertigo for some days before may be complained
of, connected undoubtedly with the high blood-pressure which is its
leading etiological factor ; or the coma may come on very suddenly without
warning. It may be followed or not by convulsions. Sometimes the
paraljrsis comes on with faintness and vertigo only ; or the paralysis may
come on more gradually, followed later by unconsciousness (ingravescent
apoplexy). Sometimes it comes on during sleep. The lesion causes
paraljrsis on one side (usually) of the body, which is indicated at first
either by a greater rigidity or a greater flaccidity, or by the absence of
spontaneous movements on that side. The pupils are unequal, the con-
junctival reflex lost. The temperature, particularly in large haemorrhages,
is usually at first one or two degrees below normal. In the course of
twenty-four to forty-eight hours the thermometer usually shows a rise of
one or two degrees, at which point it remains for several d&ys. A rapid
elevation of temperature within a few hours of the seizure indicates
haemorrhage of the base, and therefore a speedily fatal termination.

Diagnosis. — In view of the importance of differentiating this condition
in an emergency, a table is given above (p. 740). It should be remembered
that apoplexy frequently supervenes in the course of chronic Bright's
disease, and therefore uraemia and apoplexy may be concurrent. The
diagnostic features of the greatest value in apoplexy are the state of the
pupils, particularly their inequality, the loss of the conjunctival reflex, and
the presence of hemiplegia. The diagnosis of the variousyarww of vascular
lesion is given in a table on the following page.

As regards the locality of the haemorrhage, the usual position (about
76 per cent.) is the internal capsule, from the lenticulo-striate artery
(Fig. 154) giving rise to hemiplegia of face and body on the side opposite
to the lesion. In about three-fourths of the cases of haemorrhage into
the ventricles there is paraljrsis or rigidity of all four limbs, and the con-
dition is uniformly fatal. Marked contraction of both pupils, or crossed
hemiplegia, suggests haemorrhage into the pons. Hurried or Cheyne-
Stokes respiration is more common with haemorrhage in this position,
and the prognosis is grave. Meningeal hcemorrhage is suggested by the
absence of definite paralysis and the presence of initial and recurring

742

THE NERVOUS SYSTEM

L§tt

convulsions. Pachymeningitis hcBmorrhagioa (hcBmorrhage into the thick-
ened meninges) is a condition giving rise to attacks of coma which difEer
(in most of the cases I have seen) from the other causes now under con-
sideration in their slow advent. It far more often occurs in lunatics and
in the dementia of old age. Conjugate deviation of the head and eyes towards
the paralysed side is frequent when the haemorrhage involves the motor
tract.

Table of the Diagnosis of Cerebral Hemorrhage, Embolism,

AND Thrombosis.

Cerebral Hamorrhage,

Middle and advanced age.

1. Arterial degeneration.

2. Vascular strain.
8. Excitement.

Bmbditm.

Thrombotit.

Any age, bat frequently | Any age.
young.

1. Cardio - valyular le-
sions, especially mitral
stenosis.

2. Thrombus in the peri-
pheral vessels.

Coma usually sudden, i Sudden onset of para-
sometimes with con- lysis, but usually no

vulsions.

loss of consciousness
or convulsions.

1. Syphmtie endarteritis.

2. Cerebral atheroma.

3. Exhausting disease ;
phthisis ; angimla.

4. Slowing of blood — e^.,
cardiac enfeeblemeat.

Paralysis may be sudden,
or after premonitory
symptoms, vertigo, oob-
vulsions. Coma un-
usual:

Prognosis. — ^About half the cases of apoplexy, taking all cases together,
recover from the attack, but with remaining paralysis. The depth and
duration of the coma are fair measures of the extent of the mischief, and
therefore of the prognosis. The signs indicating deep coma, which are
therefore of unfavourable import, are loud stertor, completely insensitive
conjunctivae, flapping cheeks, and increasing cyanosis. Convulsions, or
the early appearance of rigidity, or a sudden rise of the temperature, are
unfavourable. Coma coming on slowly and progressively increasing
(that is, ingravescent apoplexy) is more unfavourable than that which
comes on more suddenly, with less complete coma. A more unfavourable
form still is when, shortly after the first attack of apoplexy, a second
supervenes ; from this the patient rarely recovers. As regards locality,
the worst positions are intraventricular hsemorrhage, basal haemorrhage,
and haemorrhage into the pons.

Etiology, — Cerebral haemorrhage is more frequent in the male sex, and
in those over forty or fifty. The rarer cases of " apoplectic seizure ** in a
person under forty are almost invariably due to embolism or thrombosis.
Heredity plays an important part by reason of the tendency to vascular
disease which runs in families. There is a marked predisposition in
plethoric persons to suffer from cerebral haemorrhage — the stout, thick-
decked build, with ruddy cheeks. Disease of the vessels is an almost

§681] TREATMENT OF APOPLEXY 743

necessary precursor to their rupture. High blood-pressure is a most
important factor in the causation of apoplexy ; it predisposes to arterial
disease, and may also determine the haemorrhage. The causes of high
blood-pressure are given in § 61 ; the commonest cause is chronic Bright's
disease, and that is why this morbid condition is so frequently associated
with cerebral hsBmorrhage. Leukaemia, purpura, and other blood diseases
may occasionally cause cerebral or meningeal haemorrhage.

Cerebral Embolism. — ^The preceding remarks have reference to cerebral
haemorrhage, but cerebral embolism involving a fairly large artery may
give rise to all the symptoms of apoplexy. An " apoplectic stroke " in
persons under forty is almost invariably due to embolism or thrombosis,
though haemorrhage may occur in children. The age of the patient, the
presence of cardiac, especially mitral, disease, or some other condition
giving rise to embolism, aids us in diagnosis (see table, p. 742).

Thrombosis of tbe Cerebral Arteries is also a cause of apoplectic seizure.

In most cases thrombosis arises from a gradual occlusion of the lumen of

a vessel by chronic arterial disease in the aged, or by syphilitic endarteritis

in the young. The supervention of symptoms, however, is usually sudden,

and in only a proportion of cases attended by coma (see table above).

Thrombosis of the Cerebral Sinnsei is not common, but may give rise to ooma and
all the symptoms of apoplexy. It may arise from caries of the skull of syphilitic or
tuberculous origin, extension from a cerebral abscess, and occasionally from the pres-
sure of an aneurysm, gumma, or other tumour ; or in association with meningitis.
Non-pyogenic thrombosis (especially of the superior longitudinal sinus) also occurs
with cachectic conditions, chronic diarrhooa. enteric fever, and marasmus in children.
Septic thrombosis and the differential signs of thrombosis of the lateral cavernous and
longitudinal sinuses are described under Intracranial Inflammation (§ 551).

The Prognosis of cerebral embolism as regards life is usually good, though
the paralysis remains, and if the causal condition remains, it is apt to
recur. In thrombosis the prognosis is good when due to syphilitic end-
arteritis, less favourable when occurring in the aged, and extremely grave
when associated with exhausting disease and anaemia.

The Treatment of an apoplectic seizure is not very hopeful. Perfect
rest and quiet are very important. The patient should, as a rule, be left
in the room where the seizure occurred — a mattress being placed on the
floor, if necessary, rather than incurring the movement necessary to raise
him on to a bed. The head and shoulders should be raised, and the
patient turned gently over to one side to prevent the tongue falling back
into the pharynx. The administration of food is, as a rule, undesirable,
at least by the mouth, for fear of it passing into the air passages, and
alcohol must be absolutely forbidden. The bladder should be watched,
and the catheter carefully passed if necessary. The patient will do no
harm for a day or two without nourishment by mouth, and the lips may
be moistened by a feather dipped in water. In cases due to embolism
nothing further can be done excepting to prevent a recurrence ; in throm-
bosis (other than syphilitic) stimulants are indicated. In hcBmorrJiage
a brisk purge should be given ; two drops of croton oil or 4 to 8 grains of

744 THE NERVOUS SYSTEM [ $ 6S1

calomel on the tongue is a good method, followed, if necessary, by an
enema of castor oil or turpentine. The chief indication is to prevent any
extension of the hcemorrhage. If the pulse is bounding and blood-pressure
is high, it is a good practice to bleed to the extent of 10 to 20 ounces ; and
these patients nearly always do well. The administration of aconite or
veratrium viride has been suggested to reduce the blood-pressure in lieu
of venesection. An ice-bag or a cooling lotion to the head is recommended
by some, and may be of some benefit if care be taken that after it is once
started there is no intermission, for the reaction in such an interval mav
increase the mischief by determining a flow of blood to the head. Blisters
to the back of the neck, and mustard plasters to the calves or soles
of the feet " to rouse the patient," are in my belief worse than useless.
Hsemostatics, ergot, gallic acid, acetate of lead have been recommended,
and belladonna may be of use.

III. Other Cteoss and fonoiional Cerebral Lesions.— Xjreneralised con-
vulsions are generally attended by some disturbance of consciousness,
and sometimes by coma, during and sometimes following the attack.
But in such circumstances the convulsions constitute the major feature,
and their causes are therefore given under that symptom (§ 597). It will
there be seen that the list of these causes corresponds very closely with
the causes of coma, and this is what one would expect; for in general
terms cortical compression is manifested by coma, cortical irritation by
convulsions, and toxsemia may be evidenced by either. If the history is
wanting, difficulty in diagnosis may be experienced. Among the chief
causes of both convulsions and coma are the following :

1. In Post-Epileftic Stupor the unoonsoiousness is not so complete as in apoplexy ;
there is no hemiplegia, and within a few hours the patient wakes. There is a history
of previous attacks if the patient is an adult.

2. Cbrbbral Tumour and Abscess may give rise to attacks of coma, which, in
the absence of a history of previous ill-health, are difficult to distinguish from apoplexy.
In such gross lesions of the brain there is (1) optic neuritis ; (2) paralysis of the cranial
nerves, and perhaps hemiplegia. Tumour of the frontal lobe, however, may oausc
no paralysis. (3) The coma not infrequently alternates with or is attended by
convulsions. (4) A history of headache, giddiness, and vomiting may be present.

3. In ono-fifth of the cases of Disseminated Sclerosis attacks of coma occur
(Charcot), lasting a day or two. and then passing into a state of stupor. In these
the face is flushed, pulse rapid, and temperature elevated to 104® or 105** F. The
tremor and other symptoms are always worse as the patient emerges from these
attacks.

4. General Paralysis of the Insane at some stage is almost invariably accom-
panied by fits of various kinds ; sometimes they are comatose, sometimes epileptiform,
with partial or complete loss of consciousness, and sometimes without unoonsoious-
ness. Unconsciousness is a very bad sign, and the patient frequently dies in such
attacks.

5. Certain Aoute and Subacute Cerebral Lesions, such as tuberculous and
simple meningitis, cerebro-spinal meningitis, and septic sinus thrombosis, may cause
coma. Coma in such conditions is usually of late onset, due to compression of the
brain, and a history and other signs are obtainable (see Intracranial Inflammation,
§ 647). However, in tuberculous meningitis coma may be of sudden onset, especially
in children. In cerebro-spinal meningitis lumbar puncture reveals the presence of thio
diplococcus. Paralysis is rare, but muscular spasm is common.

§ 681 ] OA USES OF COM A 746

IV. Intoxication, or Acute Alcoholic Poisoning. — ^The coma which super-
venes after heavy drinking, or a single large dose of alcohol, may very
closely resemble apoplexy and cerebral compression from head injury.
In any case of doubt it is wise to admit the patient to the hospital, or to
treat him on the supposition of the more serious condition. If house
surgeons would bear this in mind, we should see less of those paragraphs
in the newspapers headed " drunk or dying." The smell of alcohol in the
breath is fallacious, as friends may have given alcohol to restore the patient.
The chief difterential features of the coma of intoxication are : (1) The
coma is rarely so profound as in apoplexy, and the patient can generally
be roused. (2) The absence of inequality of the pupils, hemiplegia, or
convulsions (see table, § 530). (3) Procure some of the urine, and add
one or two drops of the urine to fifteen drops of a chromic acid solution,
made by adding one part by weight of potassium bichromate to 300 part«
by weight of strong sulphuric acid. The solution turns a bright emerald
green if alcohol be present in quantity (Anstie).

v. In opiom poisoning the patient becomes progressively drowsy, and
(1) coma succeeds gradually. (2) The pupils are equal and extremely
contracted ; (3) the pulse and respirations are slow ; (4) there is no hemi-
plegic rigidity or flaccidity of the limbs ; (5) the coma gradually deepens,
the face becomes cyanotic, and the puke and respiration gradually cease
t-ogether.

For the symptoms of poisoning by other narootio drugs the reader is referred to
manuals on toxicology, but it is well to remember that chloral and chloroform, coal-gas,
belladonna, the bromides, cannabis indica. and occasionally h3rdrooyamc acid, may
all act as narcotic poisons.

VT. Unemia (" serous apoplexy " of older authors^) may load to coma
in the advanced stages of kidney disease. (1) The coma is rarely qivte so
profound as in apoplexy ; it is more of a stupor or drowsiness, which
gradually^deepens. (2) In the great majority of cases, stupor alternates
with convulsions, and in many oases it alternates with muttering delirium.
(3) There is an absence of hemiplegic rigidity or paralysis. (4) There is
albuminuria. It must be remembered, however, that in most cases of
coma of sudden onset some degree of albuminuria is present. (5) If a
history is obtainable, the earlier symptoms of uraemia will be revealed
(§ 270).

Vll. Diabetic coma supervenes very suddenly, often in apparent health, and is
very profound. Its two characteristic features are (1) the sweet odour of the breath,
somewhat resembling that of chloroform, and (2) the presence of sugar in the urine.
It almost invariably results in death, being one of the most frequent modes of termina-
tion in that disease.

VlU. Hepatic diseasei which result in destruction of the secreting tissue of the
livor — notably the later stages of cirrhosis and acute yellow atrophy — give rise to a

^ The older authors recognised the clinical resemblance of ursemic coma to the coma
of cerebral apoplexy, but they found no intracranial hsemorrhage. In cases of chronic
Bright's disease the cerebral convolutions waste, and the space is occupied by the
effusion of serum on the surface of the brain, which was therefore regarded by them
as the cause of coma ; hence the term " serous apoplexy."

746 THE NBBVOUS SYSTEM [ §

condition clinically resembling ursemia. dinioally this condition is in most
differentiated by the jaundice, slight in the concluding stage of cirrhosis, very marked
in acute yellow atrophy. The coma under these circumstances has been called
cholsemia. under the impression that it is due to the presence of bile in the Mood ;
but bile freed from mucus injected into the blood does not give rise to symptoms.

IX. Heat-ftroke (sun-stroke) is classified into (1) a cardiac or syncopal variety, in
which the patient suddenly goes off into a dead faint, with symptoms pointing to
failure of respiration and circulation ; and (2) a '* cerebro-spinal " variety in wluoh
coma gradually supervenes. The circumstances under which it occurs are the only
means of its differentiation. The comatose form is described in § 375.

X. Certain rare diseaiei — e.g., Addison's disease and Raynaud's diieaie — are occa-
sionally attended by sudden coma, perhaps with vomiting and hemiplegia. A
malignant form of malaria (§ 378) is attended with coma which, coming on suddenly,
may lack a history ; and English trained medical men newly arrived in India may
mistake these oases for apoplexy. Excessive muscular exertion has caused coma,
probably due to accumulation of toxic products (Dr. V. Poore, the Lancei, 1894, vol. f..
p. 1066).

Fat embolism may cause ooma. This oocurs rarely as a complication of fraotnre.
especially compound fracture or fracture of atrophic bones. The condition is attended
by dyspnoea, either cyanosis or pallor, collapse, cardiac irregularity, and at times
by coma and death. Coma may follow oertain forms of poisoning, as in botulism,
after eating infected sausages ; these cases have a history of gastro-intestinal irritation
preceding the coma. Coma may occur in cases of severe anaphylaxis.

The Prognosis of coma is always grave, and the gravity increases with
the depth and the duration of the coma. The coma after head injury usually
comes under the care of the surgeon. The coma of apoplexy and other
vascular lesions has been already dealt with. Tn post-epileptic coma, if
the patient does not recover witiiin a few hours, the status epilepticus is
present. Such a condition being very rare, the diagnosis should be care-
fully reconsidered. Coma due to degenerative conditions of the nervous
system is usually recovered from, leaving behind perhaps a temporary
paralysis. Coma occurring with tumour of the brain or acute lesions is
usually fatal. The prognosis of opium poisoning depends upon the time
which elapsed before the patient was seen, the treatment adopted, and the
vigour with which it was carried out. Uraemic coma is not so unfavourable
as might be thought ; cases recover with proper treatment, but sooner or
later the condition recurs. In diabetic coma the patient rarely rallies.

Treatment. — Apoplexy has been already dealt with, and the treatment
of head injury is carried out on similar lines, bearing in mind that surgical
aid is necessary in many cases. Many cases of coma (other than apoplexy)
may be relieved, temporarily at any rate, by lumbar puncture (p. 897,

626) — fracture of the skull, cerebral tumour, intracranial inflamma-
tions, and even ursemia — and cures have been reported. It deserves ex-
tensive trial. For alcoholism and all forms of poisoning a prompt emetic
should be given ; a hypodermic injection of apomorphine is one of the
best remedies. Opium poisoning is treated by frequent washing with the
stomach-pump. Coffee, atropine, or strychnine are given if the heart
or respiration be failing. The patient must be kept awake by walking
him about, applying electricity to the limbs, ammonia to the nostrils, and
artificial respiration. For uraemia eliminate the poison in the blood by
brisk purgatives, hot packs, venesection, and saline injections.

§§ 588, 688 ] DEFECTS OF SPEEOH 747

§582. Coma in Children, apart from injury, may be due, in order of
frequency, to post-epileptic stupor, tuberculous meningitis, post-basal
meningitis, suppurative meningitis, cerebral tumour, syphilitic pachy-
meningitis, sinus thrombosis, and hsemorrhage ; diabetes, abscess, and
cysts are rare causes. The history, mode of onset, and associated symp-
toms aid the diagnosis. Tuberculous meningitis is by far the most fre-
quent cause. Out of 86 cases of coma in childhood, Dr. F. E. Batten
found tuberculous meningitis in 50 cases, non-tuberculous meningitis in
17, and cerebral timiour in 16 cases. Cerebral haemorrhage occurs chiefly in
association with the specific fevers, such as small-pox and whooping cough,
also with rickets and scurvy. In marasmic conditions thrombosis of the
longitudinal sinus (§ 551) may ensue, together with meningeal hsemorrhage,
giving rise to convulsions followed by coma. Thrombosis of the veins of
Galen (§ 625), and lateral sinus thrombosis, which occurs with ear disease,
may cause coma.

P, Partial Mental and " One Faculty " Defects.

One faculty of the mind, such as the memory or attention, may be
affected, and there may also be various partial mental defects which
do not amount to insanity, though they may constitute its earlier phases.
These will now be considered —

Defects of speech (motor and mental).
Defects of memory (partial and entire).
Defects of attention (deficiency and excess).
Defects of other mental faculties.
Hypnotism.
CSatalepsy and trance.

§ 588. Defects of Speech and other Signs of Thought may be purely motor, or they
may be of central or mental origin (ideo-motor or ideo -sensory), but it will bo con-
venient to consider them both here, as they are so frequently associated. All of these
defects may be simply and graphically represented in the following scheme :

Defective Oonunnnioation with others.

'motor defects (paralysis).

Defects in the outgoing processes

ideo-motor . . . ^ ®^^

V writing.

Defects in the incoming processes

jideo-sensonr • • . {^^^y.

I blindness or deafness.

Motor defects of speech are recogmsed by an error in artioolation. The patient
says the words, but pronounces them badly, just as in cases of motor defect of writing
the patient can sometimes write, but writes badly. The muscles of speech are those
of the lips, tongue, palate, larynx, and respiration, and these, like other muscles, may
be the seat of paralysis, tremor, spasm, or inco-ordination.

Clinical Investigation. — In order to investigate a case of motor defect of speech, we
must (1) pay attention to each of the different muscles just named. In the course of
conversation with the patient we can generally detect any of the motor defects which
are mentioned below. If not, we may ask the patient to repeat the alphabet through,
and we shall readily detect any paresis or other defect of the muscles. (2) Notice
whether there be any tremor of the lips or of the tongue when protruded ; any separa-

748 THE NBBV0U8 8Y8TEM £ f

tion of syllablefl ; syllabio utterance ; or, on the other hand, any dorring or mnning
together of the words. (3) The presence of any hemii^egia, facial paralysis, or other
paralysis should be noted. (4) If all these tests be negative, and still the patient n
unable to communicate his thoughts properly, turn to Mental Aphasia, § 534.

1. Paralyfii of the mufcles of the lips, face, and tongue is met with in most cases
of hemiplegia in the early stage. Here one side of the face is generally obvionslj
affected, especially its lower part, and the tongue, when protruded, deviates to tike
paralysed side. The speech is thick, and often quite unintelligible. But as the £aoe
and tongue recover, the speech returns. This is a pure defect of the musck^s of
articulation.

2. Partial paraljsii of the muscles of articulation is met with in its most typical
form in the case of bulbar paralysis (glosso-labio-laryngeal paby) and pseudo-bulhar
paraylsis. At first, when the tongue is chiefly affected, difficulty occurs with the
Unguals, L, N, T, and there is an obvious difficulty in pronouncing words, so as to give
the impression of the tongue being too large for the mouth. Soon after this the
labial letters also give rise to difficulty (as P, B, M) ; then the palate becomes involved,
the speech becomes nasal, and difficulty occurs with guttural letters — K and Q (hard).
Towards the end of this affection speech is totally lost (alalia), and the patient oan
only utter meaningless grunts.

3. A fine tremor of the Upi with glairing speech is very characteristic of genend
paralysis of the insane. The syllables are run together as in intoxication — ^'* British
Constitution ** becomes " Brish Conshon." It is also met with in delirium tremens,
some cases of meningitis, and occasionally in disseminated sclerosis.

4. A monotonous, drawling, indistinct speech is very characteristic of paralysis
agitans.

5. Syllabic or staccato speech is more characteristic of disseminated sderasis than
the preceding ; there is a pause between each syllable, and each syllable of a word is
equally accentuated (con-sti-tu-shon), as in scanning Latin verse ; hence sometimes
called '* scanning speech." Occasionally this kind of speech is met with in tabes
dorsalis.

6. Stammering is a spasmodic disorder of the muscles of articulation and respira-
tion. The condition resembles a spasmodic tic (§ 693) of the muscles of respiration
initiated each time by an attempt to speak. Other tics occur in these patients. Most
difficulty is experienced with words commencing with explosive or labial letters —
B, D. P. T, K, or G. Excepting in bad cases, the patient can whisper or sing without
a defect. In severe cases the spasm tends to spread to other muscles of the &C8 or
other parts ; the patient, for example, remaining with his mouth wide open, or his
face screwed up into some contortion for an appreciable time before any sound is
uttered. The affection appears in childhood, and there is very generally some heredi-
tary or other manifestation of defect in the nervous system. Syllable stumbling is a
variety of stammering in which one or more syllables of a word are repeated. The
curability of stammering depends a good deal upon its previous duration and the age
of onset. It is worse when it comes on in the adult. The Treatment is a matter for
very careful education, and there are some very good teachers who make the cure of
it their speciality. Much can be done by teaching the patient to manage his breath,
and always to take a deep breath before starting to speak. I have frequently been able
to assist such patients by instructing them to beat time with their hands, and, without
actually singing, to adopt a sing-song method of speech.

7. Lalling or infantile speech is that in which the letters difficult to pronounce —
e.g.f B, L, 0, Sh — are avoided ; British is pronounced Bitty.

8. In idioglossis the child has a speech of his own, which is unintelligible exoepting
to those accustomed to the child. It is due to a defective power to reproduce the
sounds of words said to him. He has to be taught by a system of lip reading. It may
occur in mongolism and cretinism.

9. BhinoUU^ operta is the speech met with in cleft palate and paralysis of the
soft palate — e.g., diphtheritic — in children. In it the speech has an unmistakable
nasal quality. In rhinolalia dansa, on the other hand, which is due to a spasm or
stiffness of the soft palate, the normal nasal quality of the speech is wanting, and this
produces the somewhat affected style mot with in some hysterical cases.

f584]

APHASIA

749

§ 584. Aphaiia is* as Trousseau aptly put it» '' loss of memory for the signs of
thought.'' In some oases the patient's speech and power of writing are so much
deranged that he cannot communicate his ideas to you ; in other cases you are unable
to communicate with the patient because he cannot recognise words spoken to or
written for him.

For speech and writing, the two outgoing processes by which we communicate to
other people, two structures must be intact, and their functions normal :

(1) The motor apparatus of speech and writing ; and

(2) Initiating centres in the cerebral cortex which have been gradually educated
up to the function of speaking and writing. These centres are appropriately called
ideo*motor centres, and contain a scries of educated recollections of the complicated
moyements necessary to produce speech
or writing.

For tlie recognition of spoken or
written language, the incoming processes
of communication, two parts also are
necessary (Fig. 152) :

(1) The sensory tracts of vision and
hearing ; and

(2) Certain receptive centres in the
cerebral cortex, ideo-iensory centres,
educated up to the art of recognising
and naming words heard and things and
words seen (see tables, p. 760).

In mental aphasia we are concerned

solely with the ideo-motor (or out-
going) and the ideo-sensory (or incoming)

centres in the cerebral cortex. Defects

of the motor apparatus of speech have

been fully considered (§ 533). and defects

of the organs of vision and hearing are

given elsewhere. In what follows we must

assume that both of these are healthy,
(a) Ideo-Motor Aphasia. — Are the

patient's powers of speech or writing

defective ? We will first consider the

out-going forms of aphasia : aphemia

(idec-raotor defect of speech) and

agraphia (ideo-motor defect of writing).

The commonest instances of this form of aphasia are associated with right hemi-
plegia. In certain cases of hemiplegia we find after a time that, although the patient
recovers the use of his lips, tongue, and arm, he is still unable to name things properly
or to converse, except by writing or by pantomime. This disability may exist in
many degrees ; in some cases the patient only occasionally says a wrong word, in others
he cannot use a single word correctly. In some of the worst cases the patient makes
use of one or two words only (recurring utterances) for all he wishes to say. His
articulation of those words which he can speak is good ; he has full power in the muscles
of the face and the arm, and his hearing and vision arc good. But there is a defect in
his mind which prevents him from recalling the movements of articulation which
indicate the word he wants to use. He knows the right word when he sees or hoars
it ; hold up a pen and suggest to him that it is a haddock ; he shakes his head and
gets angry ; write on paper or say " pen," and he nods and smiles. Such a case repre-
sents one of the commonest kinds of aphasia ; it is a loss of memory of the co-ordinated
movements of speech, and is known as aphemia.

Take another and rarer case, and suppose that, instead of speech, it is only the
power of writing which the patient has lost. His motor power is good, his speech
correct, and his vision and hearing perfect. But he cannot write a word, although he
knows the word he wants to write. In short, he has loss of memory for ihe co-ordinated
movements of writing, and the condition is agraphia.

Fig. 162.— Apparatus of Sprboh (represented in
error in the right cerebral iiemisphere). — The
auditory and visual ideo-sensory centres and
the ideo-motor centre of speech.

750

THE NERVOUS SYSTEM

[fm

Thus we have two kiDds of possible defect of a patient's outgoing, initiating, or
ideo-motor centres in the oortex oorreeponding to the two principal means by which he
communicates his thoughts to the outer world (see table, below).

Ideo-motor Aphasia i.e., defect in the cortical mechanism of the centres

of speech and writing.

TeiU.

Nature of Defect.

Poeitum of LtHomt
im Cortex Cerebri.^

Speech lou
(aphemia).

Cannot talk correctly
or say names of ob-
jects.

Writing loss
(agraphia).

Cannot write names
of objects or con-
vey his thoughts in
writing.

Loss of the educated
recollection of the
movements required
for spoken words.

loss of the educated

recollection of the

movements required
for writing.

Posterior end of third
left (in moat people)
frontal oonvoliitian
(Broca's) and lower
end of aaoeodiiiig
frontal (Fig. 153).

Posterior end of secood
left (in most people)
frontal oonvolattoii.

(6) Ideo-Semory Aphaiia (Sensory Aphasia). — Can the patient understand
or spoken words ? Let us now consider the incoming forms of aphasia — visual
aphasia (word-blindness) and auditory aphasia (word-deafness). They may be
unattended by any defect of speech, vision, or hearing for ordinary purposes. Bat
the patient has simply a loss of memory for the signs of other people's thoughts ma
expressed in written or spoken words.

First, as regards wobd-blindness (visual aphasia). We have a visual recording-
board (Figs. 162 and 153) in the cerebral cortex, upon which our recollection of printed
or written words is recorded, so that after seeing them a few times, or being educated
to read, we can recognise and name them at once when seen again. If ^e patient
has lost the faculty of understanding and recognising written or printed words, the condi-
tion is word-blindness (visual aphasia). This form may be met with alone. The
vision is good enough for ordinary purposes, but it is a curious circumstance that in
most of such cases the patient cannot see with the left half of each retina (hemianopsia),
because it so happens that lesions in the occipital lobe which produce word-blindness
also cut off the optic radiations which come from one optic tract.

IdeO'SENsory Aphasia i.e., defect in the cortical receptive centres for

word-vision or word-hearing.

Word - bUnd-
ness (visual
aphasia).

Teett.

Can see, but cannot ,
read or recognise
printed or written
characters. Usually
with left homony-
mous hemianopsia.

Nature of Defect.

Loss of the educated
visual memory for
written (or printed)
signs.

Word ■

1
• deaf-

ne38

(audi-

tory

apha-

sia).

Can hear, but cannot
understand or recog-
nise epoken words.

Loss of the educated
auditory memory for
speech.

PontioH of Lesions
in Cortex Cerebri^

Angular gyrus (visoal
speech centre) ; or
in the left ocdpltal
lobe, so situated as
to sever the optic
radiations between
the angular gyros
and the visual
centre.

Posterior half of the
superior temporo-
sphenoidal (W^er-
nicke's) convolution
(auditory word
centre).

^ Note that these centres arc ordinarily situated in the left hemisphere, but when
the patient is lelt-handed they are situated in the right hemisphere.

§584]

APHASIA

761

Secondly, as regards wobd-deapness (auditory aphasia) — uc, the non-reoognition
of spoken words. As in vision, so in audition, we have a recording-board in the
cerebral cortex, by which we recognise spoken words. It is by the auditory memory
that we learn to recognise such sounds as " mamma " and " papa," and afterwards
other sounds in our own and other languages. When a patient's faculty of hearing
for ordinary purposes is intact, but he cannot understand spoken words, the condition
is word-deafness (auditory aphasia). This is the rarest form of aphasia, for the
recognition of sounds and spoken language is the first thing we learn, and, as a general
neurological principle, the faculties first to come are less easily damaged than later
acquirements. It is practically always associated with word- blindness, and generally
also with ideo-motor aphasia.

I have described these four varieties of memory of the signs of thought singly in
order to make the subject clear, but they are all interdependent one on another. The
complete memory for a pen, for instance, involves a visual recollection of the object
and its printed sign, an auditory memory of the sound " pen," and an ideo-motor
recollection of the movements used for saying or writing *' pen." In point of fact,
the four varieties of aphasia which correspond to these forms of memory are nearly
always mixed in various proportions, aphemia being the most common, agraphia the
next, word- blindness the next, and word-deafness the rarest. This renders their
investigation difficult. Par-aphasia was
a term used by Kussmaul to indicate
a slight degree of mental aphasia with
var3ring admixtures of aphemia, word-
blindness, and word-deafness, leading
to the misplacing and misapplication
of words. Par-agraphia was used by
him to indicate slight degrees of mis-
takes in writing.

Lesions, — Pure cases are, as just
mentioned, very rarely met with, but
now and then such oases have been
observed, and we are thus able to locate
the position of the several lesions in the ^*8- 153.— M.S., ideo-motor centre for speech.
«^-.*«^ TU^^ ^m^ ^^^^ :^ 4-Ur. 4-^ui^^ ^ M.W., ideo-motor centre for writing. W.B.,
^^"^^ J^®^ ff^ ?7^^,^ *^® ^*^!^' £ centri damaged in word-blindneas. w!d.. centri
and in fig. 153. Usually the lesion damaged in word-deafness.

involves the grey matter of the cortex,

ocoasionally the white strands beneath. The changes may be structural, as in cases
of haemorrhage, embolism, thrombosis, or tumours ; or functional, and leave no trace
behind them.

Clinical Investigation, — One so seldom meets with aphemia, agraphia, word-blind-
ness, or word-deafness alone that the investigation of a case of aphasia is not easy,
and it becomes a question as to which of these predominates.

(1) First ascertain whether there is any, or how much, defect in the articulation or
motor apparatus of the face, tongue, or arm.

(2) You will find it oonvenient to proceed next to investigate the patient's power
of oomprehending your communications to him, in the inverse order of the description
I have given above.

(3) Word-deafness, the rarest^form of aphasia. — Qive the patient some simple
spoken order — e.^., " shut your eyes " — but do not accompany your spoken orders
by any gesture. If he responds, there is no word-deafness ; if he does not respond,
he is either deaf (an unlikely thing on both sides), or he is word-deaf ; and you must
ascertain that he is not deaf by seeing if he turns his head towards a sudden noise or
musical sound.

(4) Word- blindness. — ^Ascertain if his sight is good, and particularly if he appears
to be able to see equally well with both halves of his retina, for word- blindness is
commonly accompanied by homonymous hemianopsia. Give him the newspaper
(upside down at first), and ask him to identify some of the letters. Then write out
some simple instruction and show it to him ; if his sight is good (except for hemianopsia),
but he does not respond, there is visual aphasia (word-blindness). In some cases you

752 THE NEMV0U8 SYSTEM [ §

oan plaoe a pen, a penknife, and a watoh before him, writing out their uamee on pieoes
of paper, and ask him to place them on the objects.

(6) Agraphia. — CSan he express his thoughts to you correctly in writing ? Aak
him to write his name, for instance, or write an account of his illness.

(6) Aphemia. — CSan he remember words he wants to say. or does he uae them in>
correctly in conversation 7 Can he name objects correctly ? Hold up a pen and sug-
gest wrong names for it, finally saying or writing ** pen," and learn by his gestures if
he knows which is the right name.

§686. Defects of Memory (Amnesia) may be (a) entire — ^forgetfulneas
for everything — or (6) partioi— forgetfulness for certain facte.

(a) Lots of memorj ai a whole may be indicated by a forgetf ulness for reoent facts,
such as what day of the week it is ; or for remote events, such as incidents of yoath ;
or by a forgetfulness of what the patient wished to say or do (intention amnesia), or
where he had placed things.

Oauees.—{l) Neuradhenia and various debiliUUing conditions, such as •-nwmia.
convalescence from severe illnesses, general ill-health, and exhaustion from over-
work are commonly attended with some defect of memory. The activity of the
memory, like that of the attention (or power of concentration of the tiiought), is
indeed a measure of the activity of the mind, and when the brain is '* tired," the
memory flags. (2) The memory is also temporarily impaired under the use of certain
drugs — eg,, large doses of bromide — but it readily recovers when this drug is stopped.
(3) In €uivancing years the memory may become permanently deficient as a normal
phenomenon (senile amnesia and senile dementia). The peculiarity of senile Mnnpfria
is that it applies chiefly to recent events and to recently acquired knowledge. The
patient perhaps can give us full particulars of his early life, and repeat poetry learned
in youth, but is unable to mention any event of the same or the previous day. (4) la
the mental condition of chronic dtcohclism, amnesia is a prominent and sometimee
incurable condi tion. For instance, a lady who was under my care for alcoholic neuriiifl
and delirium three years ago, has now recovered both in mind and body, except that
she is unable to recall a single fact or incident for five minutes at a time. (5) D^Eective
memory is also met with as a symptom of dementia and other forms of ohnmic insani^.
The patient puts things away and forgets where they are ; he also forgets where he
is and what he was going to do. (6) Sudden obliteration of memory is not unknown.
It may occur after a severe illness, and a portion or page of the recollection becomes
blotted out, the patient picking up the thread of his life where it left off ten or twenty
years before. The case is mentioned by Sir William Gowers of a clerg3rman aged sixty
who obstinately believed he was forty, and picked up the thread of his life at that age.
Sometimes suoh sudden obliteration occurs after epilepsy or without known cause.
as in cases reported in the papers from time to time of persons who have forgotten their
name and all particulars about themselves.

(7) Dual personality (Synonyms : *' dual consciousness," " alternating oonocious-
ness ") is another mentsl condition, in which loss of memory is a prominent feature.
It is a rare and interesting condition, in which a patient lives alternately two dififeretit
lives, or rather, has two alternating mental states, which may for purposes of descrip-
tion be called State A and State B. The essential peculiarity of the condition is
that the patient when in State B has no recollection of his thoughts and acts while in
State A, and vice versa. In each state he picks up the thread of his life when he was
last in that state. Moreover, while in State B he may behave in a totally difEerent
manner to that in which he behaved during State A. He is subject, in otiier words,
to alternating states of consciousness and character, in which the whole mental attitude
and mental record is changed. As a temporary condition dual consciousness may
occur after epilepsy (masked epilepsy, or minor epilepsy chiefly), or after hysterical
attacks. As a more permanentiy alternating condition it is found in some without
this association.

(6) Among the partial lotsei o! memory—

Mental aphasia may be mentioned. It is, as we have just seen (§ 634), a loss of
memory for the signs of thought.

Verbid amnesia is really a slight degree of ideo-motor aphasia manifested by an

§ 686 ] DEFECTS OF MEMORY 753

inability to reooUeot the words or names when the patient wishes to speak. It oooors
with a tired brain or after some emotional shook.

ininal and Auditory Amneiia. — Many interesting observations of late years go to
show that the memory is compounded of different constituents. Apart from the
association of ideas, there are two distinct means by which different individuals recall
an idea, (i.) Some recall an idea by a visual impression, such as the form or colour of
the object it represents, or by the image of the printed word representing it which
they have seen or read. This is called a visual memory, and people who chiefly use
this form, remember those ideas best which were originally conveyed to them by
pictures or objects seen, or by reading a descriptive passage to themselves, (ii.) Others
can best recall an idea which is conveyed to them through their ears — e.g., by sounds
or by words read aloud to them — and these have what is called an auditive memory.
Though everybody possesses both these forms of memory, they unconsciously make
use more of one than the other. The visual memory of most people is better than
their auditive memory, and they recall objects and pictures seen much more readily
than sounds heard ; hence the great value of kindergarten and demonstrative methods
of education. Charcot narrates a remarkable case of a highly educated man, a
banker, who, having an unusually good visual memory, suddenly, after a severe
emotional shock, lost it completely. He was conscious of a great blank in his mind,
and was unable to picture to himself any of the forms with which he had formerly been
familiar, such as the shape of a building, a column of figures, the colour of his wife's
hair, etc. By degrees, however, he learned to substitute his auditive memory, which
hitherto had lain dormant, and so he gradually became able to carry on his business
again. 1

y. Acute Perversions of the Mind (Delirium and Mania),

§586* Acute mental exaltation or excitement occurs clinically in two

forms — delirium and mania — which differ, however, less in their clinical

features than in the circumstances under which they occur. I. Delirium

is the term applied to mental excitement which is clearly traceable to some

bodily disorder of which it is a symptom or complication. II. Mania is

the term applied to mental excitement when no such source can be traced,

the mental condition being the only — or, at any rate, the principal —

symptom. III. Actvoe or a,cute melancholia is occasionally met with ; it

only differs from chronic melancholia (§ 539) in the misery and depression

of the patient being of a more aggressive character. Mania is practically

always acute ; melancholia nearly always chronic. Both are liable to

relapse. The one frequently follows on the other, and by many authorities

they are considered as phases of one disorder — Manic-Depressive insanity

(Kraepelin).

Clinical Investigation, — The first and most important point in any given case of
delirium or mental excitement to which you may be called for the first time is to
ascertain the temperature, for the most useful clinical division of the causes of delirium
is into Febrile and Non-febrile. Secondly, it is important to make a thorough and
oompiete investigation of all the organs of the body, to ascertain whether there be
any local inflammatory disorder, such as pneumonia, with which delirium may be
connected, either directly or indirectly. I remember once overlooking a case of latent
pneumonia, and consigning it to the lunatic ward of the workhouse. The urine also
should be carefully examined for albumen, sugar, or other abnormality. Thirdly, an
inquiry should be made into the history of the malady and of the patient, especially
as regards alcohol. In reference to the etiology of delirium, three important predis-
posing causes have to be borne in mind. First, there is a marked predisposition in

^ " Le9on8 Cliniques but les Maladies du Syst^me Nerveux/' tome ill., Le9on 13.

754 THE NERVOUS SYSTEM £ § 5W

some nervous people to develop delirium in presence of a slighter cause than wonM
be operative in others. Secondly, there is a marked hereditary tendency towarda
the same vidnerability ; and thirdly, excessive drinking predisposes to the oceiaxTeioce
of delirium after an injury, operation, and many diseascis which are not usually so
attended.

I. The causes of delirium have been considered (§ 345), and need only
be here enumerated.

Febrile. I Non-fArUe.

Diseases of the brain — especially

meningitis.
Acute visceral inflammations.
Acute specific fevers.
Delirium tremens (rare cases).

Delirium tremens.
Chronic renal disease.
Post-febrile delirium.
Reflex delirium.
Deliriant drugs.

II. Acuts Mania may supervene suddenly — (1) during convalescence from ex-
hausting diseases (as previously mentioned) ; (2) in the course of other diseases of the
nervous system — e,g,, G. P. I. ; (3) in the course of some other form of insanity. Its
onset is usually rapid, tongue- tremor being often met with in the early stage (Sir 6.
Savage). The stage of excitement is soon reached — ^loquaciousness, sleeplessness,
continual restlessness, incoherence, in which delusions and ideas succeed each otiier
with great rapidity, sometimes relating to moral and religious, at other times to
intellectual topics. After lasting some weeks or months, recovery (sometimes quite
suddenly) ensues ; sometimes it is followed by moral or mental obliquity or dementia ;
rarely it passes into chronic mania. The temperature is normal throughout. In
many cases there is a tendency to relapse.

Acuts DeliriouB Mania (Bell's Mania) is an acute maniacal condition coming on
suddenly in a person in apparent health, attended by pyrexia, usuaUy running a
rapidly fatal course, no lesions being found after death. It is happily a somewhat
rare disease. The symptoms come on abruptly, and quickly amount to frenzy.
accompanied by outbreaks of great violence and refusal of food. The temperature
ranges irregularly from lOO*' to 104^ F., and in the course of one to three weeks the
disease terminates in great bodily prostration, and usually in death. Acute delirious
mania differs from acute mania in the elevation of temperature, the rapid wasting, and
its more rapid and fatal termination. It resembles some oases of enteric fever veiy
closely, acute pneumonia and acute meningitis, but their proper symptoms are absent.

The Treatmevi of mania consists mainly in the administration of food (with stimu-
lants if the pulse so indicates). Narcotics and depressants may be tried, and Sir 6.
Savage mentions a case which apparently got well under frequent small doses of
opium. For acute delirious mania the wet pack or the graduated bath (§ 392) may
be given. Professor Osier recommends venesection.

in. Acuts dementia (" itnpor ") is a rare condition of sudden ablation of the mental
faculties (vide XIV., p. 762).

5. Chronic Perversions of the Mind (Insanity).

§687. This is a more complex group than any of the preceding, and

it forms the collection of morbid conditions of the mind, known as insanity.

The subject may be briefly dealt with under —

Chronic mania { 538

Chronic melancholia § 639

Chronic dementia § 540

Special types of insanity, such as general paralysis of the insane ; delu-
sional insanity ; dementia precox ; epileptic insanity ; hysterical
insanity ; moral insanity ; obsessional and impulsive insanity ; alcoholic,
syphilitic, and puerperal insanity ; catalepsy ; trance . . § 641 and § 642
The mental defects special to children and adolescence . . § 546 and § 546

§§688. 689 ] OH RON 10 PERVERSIONS OF THE MIND 765

Clinioal Ikyestioation. — I have already, in § 513. referred to the importanoe of
tact and general knowledge in investigating psychical disorders, and I may here
mention two other points : (1) Get your data in chronological sequence as far as
possible ; and (2) never be in a hurry. Any careless, inept, insistent, or rapid ques-
tioning will only confuse and silence your patient and defeat your object. Ckiin his
confidence ; let him talk to you first of his favourite hobby, then of his thoughts and
feelings, and finally of his delusions or hallucinations. The main points to investigate
in mental cases are sleep (and dreams) ; speech ; writing ; memory ; decision and wiU ;
reasoning power ; moral and ethical standards ; delusions ; hallucinations ; and, lastly,
whether the patient regulates his conduct according to those — i.e., whether he (or
she) is a potential danger to himself or others. Before committing yourself to an
opinion never omit to ascertain from the relatives how far the patient*s present differs
from his previous character and conduct, for conduct that is mad in one person is normal
in another.

The three terms, dduaion, illusion, and JuUlucination, strictly speaking, have different
meanings, but they are used somewhat laxly and indifferently. A hallucination is a
false sense perception without any external stimulus — e.g., the hearing of voices
and the seeing of snakes. Illusions are distortions of sensory perceptions, as in alco-
holic delirium, when a lady^s muff is thought to be a cat. A delusion is a false idea
or judgment which cannot be accepted by people of the same class, education, race,
and period of life as the person who expresses it. It is predisposed to by a state of
depression or of elation, and may be excited by hallucinations. Hallucinations aro
met with particularly in exhaustion, mania, delirium, mania e potu and paranoia,
and it is surprising what minute details can be given to us about these creations of
the mind. Hallucinations of sight (rats and snakes) are much less common than
those of hearing (hearing voices). Hallucinations of taste and smell are present not
infrequently in association with delusions of being poisoned. Hallucinations of
common sensation are both frequent and various, and are especially frequent at the
climacteric and in hysterical subjects who become insane. Amongst the varieties of
sensation hallucinations of the male or female sexual organs are not infrequent, and
in this way false accusations may be made against those (especially doctors and nurses)
with whom the patient comes in contact.

In regard to all delusions, illusions, or hallucinations, it is important to estimate as
far as possible how far such perversions of the mind influence, or are likely to influence,
the acta or conduct of the individual.

After noting the age of the patient, the first question to investigate in the history
is whether the attack came on with excitement or with depression. If with excite-
ment, the case may be one of mania or general paralysis of the insane or delirium
(§ 536). If the case came on with depression, it may be melancholia or Q. P. I. If
the patient is an adult, start at § 638 ; if an adolescent, at § 545 ; if a child under ten,
start at § 646.

§ 688. I. Ohronio Mania is simply a prolonged form of acute mania, as previously
mentioned (§ 536), lasting with less excitement for years, instead of for weeks or
months. Beourrent mania is that which recurs, sometimes at the menstrual epoch.
" Folie ciroulaire " is an alternation of mania and melancholia, with lucid intervals.
Monomania was used by Esquirol to indicate a form of delusional insanity (§ 542)
dominated by one fixed idea ; it is not really mania.

§ 689. n. Chronic Melanoholia is a morbid condition of miserable self-consciousness
and self-abnegation without hope. Melancholia occurs under three circumstances :
(1 ) It may be part of some other mental disorder, such as G. P. I., or a stage (first or
third) of mania ; (2) it may constitute the whole of the mental disease without previous
ill -health ; or (3) it may supervene on neurasthenia or some bodily ailment. The
onset is usually insidious, and commences with extreme self-consciousness, combined
with sadness, as indicated by tears without cause, and when the patient is remon-
strated with he is irritable. There are morbid dreads of impending calamity which
cannot be named, sleepless nights, and a suicidal tendency. Among the physical signs
commonly noted in such oases are feeble circulation, as evidenced by cold feet and
chilblains, and constipation. Melancholia differs from hypochondriasis in the " hope-
lessness " of the former and apathy to surrounding conditions.

756 THE NERVOUS SYSTEM [ § Mt

Foot varieiies of melancholia are deeoribed — active, passive, and simj^e melancholia,
and melancholio stupor. (1) and (2) Active and passive melancholia depend upon the
degree to which patients give expression to their grief. In the former they are alwBjs
imparting their trouble to someone ; it is in reality an acute melancholia. In the latter
they sit for hours together in a dejected state, and it is sometimes difificult to ehdt
their leading delusion. (3) Simple melancholia may be described as melaocbolia
without definite delusions. It consists simply of misery, sleeplessness, self-blaiiie,
and inability to continue at work. This form is common in the overworked or mooh-
worried, and in women at the climacteric. Suicide is not uncommon in theoe cases. '
and precautions, which are sometimes neglected on account of the simf^icitj of the
affection, should not be omitted. Otherwise the prognosis is favouraUe. (4) In
melancholia with stupor (melancholic stupor) the patients remain speeohlesa and
motionless, with an aspect of abject misery. Their limbs may be flaccid or in cata-
leptic rigidity. They are abstracted and oblivious to all external stimuli. They
resist external interference, but are not usually violent. The condition may oome on
suddenly or gradually, and last for months or years. Some cases end fatally in a
short time. Some have recurrent periods of exaltation. Some terminate in a condi-
tion of permanent weak-mindedness, and a few recover. It is equally common in both
sexos, but is more frequent in the young than the old. Sometimes it follows a sever*
and exhausting illness, and sometimes it follows acute mania.

Course and Prognosis, — ^Tho melancholic process is longer than the maniacal one.
The duration varies considerably, but lasts an average of some three to twdve months.
Relapses are not infrequent. The slower the advent of the disease, the slower is thf
rcK;overy. Recovery is common enough in the young, the prognosis being worse ae
age advances. Suicide is frequent in all forms, but death from the disease is rare.
Heredity is an important factor, and the nutrition of the body at the time is another.
The melancholia of pregnancy is ^vourable, but the melancholia of lactation is always
grave. It is interesting to remember that cases of melancholia may recover even after
a very long time (nine, ton, and thirteen years have been recorded). There is a distinct
suicidal tendency in all cases of melancholia, but those are specially liable, according
to Sir G. Savage, who have delusions of impotence, of being followed or persecnted,
of hearing voices, of being the cause of injury to their relatives, or who are stuffering
from great physical weakness or bodily disease. The tendency to suicide appears to
increase with age, and suicidal cases generally have an insane heredity, and often a
suicidal heredity also. Patients generally have a special predilection for some par-
ticular mode of death — one to poisoning, another to drowning, another to tij^tigmg.
and another to blowing his brains out, and they will often avoid other means which
may happen to present themselves.

In regard to Causation, melancholia depends in most cases more upon physical and
external than upon mental and moral causes. Some of the commonest causes haw
been referred to under the variety Simple Melancholia. No doubt want of society.
solitary habits, combined with a sedentary life, in which the person is debarred from
genial companionship, are the prominent causes of this condition. A general depres-
sion of the vital powers — e,g., from bodily disease, fevers, heart disease, etc. — is an
important factor. Any age may be affected, but it mostly arises at or after middle
life.

Treatment. — In the simpler cases, such as those referred to under Simple Melancholia,
a few weeks* rest under supervision, with a pleasant companion and complete absence
of the conditions under which the disease arose, followed by a few months* easy travel.
will generally set the patient right. If the interest can be aroused, and the att^fitioo
attracted for a sufficient time, much can be done to relieve the condition and even
remove the delusions. Feeding is necessary, and in case of refusal it may be done
by means of (a) a spoon, pouring the fluid into the cheek beside the teeth, or (6) by
the nasal or stomach tube. The quantity thus administered should be equal to 5 pints
of milk, 2 pints of strong beef-tea, 6 eggs and 3 to 6 ounoes of brandy per diem. Soicide
must be prevented by removal to an asylum or careful watching at home.

§ 640. IIL DementU is deficiency of all the mental faculties, coming on in adult
life. It comes on as a primary condition in (a) chronic alcoholism, and (6) advanced
life (senile dementia). The first, as we have seen, shows itsdf especially by a loss of

§641] GENERAL PARALYSIS OF THE INSANE 757

memory. The second also has the same peculiarity, with the additional feature that
the memory is lost for recent events only. Dementia comes on as a secondary condition
in (a) general paralysis of the insane, and as the concluding stage in many other forms
of mental disease, notably dementia prsecoz ; and (6) after vascular and other gross
intracranial lesions. Even after a small lesion of the brain the mental capacity for
business is hardly ever as good as before its occurrence, and the patient often becomes
childish, peevish, forgetful, emotional, and by degrees in severe cases, completely
demented.

The Special Forms of Insanity are general paralysis of the insane ;
delusional insanity ; dementia prcecox ; epileptic insanity ; hysterical
insanity ; moral insanity ; obsessional and impulsive insanity ; alcoholic,
syphilitic, and puerperal insanity ; catalepsy and trance.

§ 541. lY. General Paralysis of the Insane (6. P. I. ; Paralytic Dementia)
is a progressive generalised muscular weakness and tremor, accompanied
by mental symptoms, often of a grandiose character, occurring almost
entirely in young men or men in the prime of life ; due to atrophy and a
scattered sclerosis of the cortex cerebri. The disease depends on a para-
syphilitic process ; i.e., it is an indirect or nutritional effect of the syphilitic
toxin (resembling tabes dorsalis in this respect), not a direct manifestation
of syphilitic lesions.

Symftoms. — Paralysis of the limbs may sometimes exist for many years
without mental symptoms {vide infra). In my own experience, mental
have generally preceded the physical symptoms, but this order varies.
The characteristic symptoms are mental alteration, general weakness,
tremor, and alterations in the pupils and the speech. They are divided
for convenience into three stages, each of which lasts about one year.
In the first or premonitory stage (the stage of irritability and muscular
tremor) irritability, restlessness, perversion of the moral sense, and loss
of the faculty of attention are among the most usual features, though a
variety of other mental aberrations are met with. A man of even temper,
who has been a fond husband and father, becomes irritable over trifles,
gives way to coarse and blasphemous language, exhibits sexual aberrations,
or commits thefts. He becomes egotistical, showing the delusions of
grandeur so characteristic of the malady, and squanders his money. He
may believe himself to be very strong, very wealthy, or very high bom.
Sometimes, on the other hand, great depression is the characteristic of
this stage ; and thus, even in this period, we find two groups, one with a
tendency to expansion and restlessness, the other with a tendency to des-
pondency and loss of energy. Accompanying, preceding, or following the
mental symptoms are various physical changes, amongst the commonest
of which are (i.) tremor (fine, small, and rhythmical) of the hands, (giving
rise to characteristic handwriting), and of the lips and tongue (giving rise
to a very characteristic speech — viz., a slurring of the words as in intoxica-
tion), (ii.) The pupils in this stage are usually small, very contracted,
and immobile to light (" pin-point pupils ") ; very often unequal,
(iii.) Headache, neuralgia, and various subjective sensations are some-
times complained of. (iv.) Weakness of the limbs, always generalised.

768 THE NERVOUS SYSTEM [ §

and sometimes combined with some inco-ordination. As a rule, the knee-
jerks are increased in G. P. I. Sometimes the symptoms of lateral or
posterior sclerosis are present. Anaesthesia and other alterations of sensa-
tion and of the special senses are frequent. The second stage (stage of fits)
is characterised by (i.) mental enfeeblement, which replaces the exaltation
in the first stage ; (ii.) increasing muscular weakness, difficulty in walking
any distance, and especially in the act of turning, sometimes combined
with giddiness ; (iii.) fits are almost invariably present at some time during
this stage ; they vary in character, but are usually syncopal or epileptiform,
with or without the Joss of consciousness. Sometimes they consist of
attacks of numbness of the limbs, or aphasia, or coma. The third stage
is the stage of progressive mental extinction. The speech becomes
inarticulate, the paralysis extreme, and may be accompanied by con-
tracture, so that the patient cannot feed himself. His mind undergoes
progressive extinction, and there is loss of all its faculties. The urine and
fflBces are passed involuntarily.

Many different varieties have been described, but these only exist in
the earlier stages of the disease; they all tend to one common form of
progressive mental enfeeblement. (1) The expansive variety is the com-
monest, and forms the basis of the above description. (2) The melancholic
variety is characterised by great depression and passes into stupor, or has
maniacal symptoms before dementia supervenes. (3) In the paralytic
variety, paralysis and tremor predominate, with few or no mental symp-
toms, excepting occasional outbursts of emotion and some change in
character. Sometimes the paralysis predominates in the legs (ascending
variety) ; the legs may be rigid (spastic form) ; and there is an ataxic form
closely resembling tabes dorsalis at the outset. (4) A congestive variety
has been described, chiefly characterised by fits of various kinds. (5) A
juvenile variety, between the ages of fifteen and twenty-five, due to con-
genital syphilis.

Course and Prognosis, — The duration varies widely from a few months
to three or more years, and the proportion occupied by these various
stages differs greatly. One thing is Very characteristic of the disease —
remarkable intermissions of comparative or complete return to health.
But these cases always break down on attempting to resume their former
state of life. The expansive form above described usually runs its course
in about three years. Where depression and melancholia are marked
features, the prognosis is worse (Bristowe), and the disease is more rapidly
fatal. The spinal paralytic or ascending form occupies a much longer
I)eiiod, and may extend to six or eight years. When the malady is once
established, it invariably progresses towards a fatal termination.

On account of its great variety, G. P. I. has to be diagnosed from many
different complaints : (a) From other forms of menUd disorder, especially
alcoholic insanity, chiefly by the tremor, speech, the pupillary changes,
and the progressive lethal paralysis ; (b) from other diseases giving rise
to generalised paralysis (see § 573) ; (c) maladies attended by tremors sokd

§642] GENERAL PARALYSIS OF THE INSANE 769

other neuro-muscular symptoms, such as disseminated sclerosis and
^paralysis agitans. Chronic alcoholism and ferifheral neuritis are difficult
to differentiate sometimes ; they are recognised by a history or evidence
of alcoholic dyspepsia, and by absent knee-jerks. Bulbar paralysis is
recognised chiefly by its S3rmptoms being confined to the mouth, tongue,
and throat, the mind being usually normal. Lumbar puncture (pp. 897
and 900) greatly aids the diagnosis of 6. P. I.*; there is lymphocytosis,
and in 97 per cent, of cases a positive Wassermann reaction. Cerebral
syphilis may be impossible to differentiate clinically ; the cerebro-spinal
fluid, however, is not positive to Wassermann's test. The diagnosis from
tabes dorsalis is not usually difficult, but these two diseases are very apt to
occur in a mixed form.

Causation. — (1) Adult males, in the very prime of their strength and
manhood — that is, between thirty and forty — ^are the favourite subjects
of the disease, but it may occur at any age. There are congenital cases.
It is generally said to be four times as common in men, but I believe it
to be conmaoner. It is more frequent in the lower classes of life. A
neurotic heredity is said to be in operation in as much as 30 per cent, of
the cases. There seems but little doubt, however, that the disease is in its
essence a syphilitic, or rather parasyphilitic process, as above mentioned.
Alcoholic, sexual, and other excesses, anxiety, and mental fatigue are
accessory causes.

Treatment, — Something may be done in the way of prevention when

there is a history of heredity by the avoidance of overstrain and of alcohol.

Patients with a hereditary taint and premonitory symptoms such as the

above should certainly avoid matrimony. The most important remedial

measure consists of the removal of the patient from the conditions under

which the disease has arisen, and especially avoidance of business and all

causes of anxiety or mental strain. He should live a regular life, with

outdoor exercise and amusements which take him out of himself. Iodides

and nerve tonics (especially cod-liver oil) sometimes do good in the earlier

stages. When excitement is present, the head should be kept cool (possibly

with an icebag) and the feet warm, and the bowels should be freely opened.

Physostigma or hyoscyamin may be given ; and if much excitement is

still present, 30 minims tinct. digitalis every four hours, or a warm bath

followed by an icebag. The cold pack is also useful, and bromide and

sulphonal. In the melancholic varieties, arsenic, iron, and quinine are

the only remedies that have been found useful. Galvanism to the centra]

nervous system has not, so far, been attended with much success. Sal-

varsan and antisyphilitic remedies in general have not given any good

result when the disease is established.

§ 542. Othtr Special Typei ol insanity are named according to their clinical features,
sach as delusional, hysterical, and moral insanity ; or according to their etiology, such
as alcoholic, syphilitic, and puerperal insanity.

V. Delnfional Insanity is a chronic form of insanity, in which the leading or solo
inentAl altoration consists of a fixed delusion or hallucination, which modifies the
conduct of the individual (compare Clinical Investigation, § 537). A delusion, illusion,

760 THE NERVOUS SYSTEM [ $ 5tt

or halluoination may arise under three oonditions : (i.) It may arise in a person "who is
otherwise perfectly sane ; (ii.) it may be associated with other evidences of insani^,
or be a sequela of a past attack ; or (iii.) it may, when no other symptom is preeent,
constitute in itself delusional insanity — when, that is to say, it controls the conduct of
the individual. Delusions, especially on religious subjects, are not at idl uncommoo
in the so-called sane. But when these delusions modify the acts or conduct of the
individual and lead him to act in an unusual manner, the condition beoomee one of
insanity.

Paranoia is the modem term used for a variety of insanity in which the patient's
whole mental life is dominated by a delusion — ^usually a fixed one of perseoutioii.
Disorder of judgment is the characteristic feature, and in consequence the patimt
interprets every incident which he observes or takes part in as fresh proof of a plot
against him. There are two classes of paranoics. In the first, which is of a miMgr
character and rarely needs asylum care, the patient's own personality does not take
any part in the delusion, but he is possessed by some wild theory which he {oeaofaes
in and out of season ; in the second class, which is a grave form of insanity, the patient's
own personality is all-important, and delusions of persecution are common. TUs
delusion is liable to lead the patient to assassination of some prominent person or
even to attempt suicide in order to call attention to his case. Hallucinations and
megalomania are apt to develop as the disease progresses. Hypochondriasis, in wlueh
the patient's attention is focussed on his health or lack of it, is sometimes a sub- variety
of paranoia, but does not lead to any disorder of conduct likely to cause harm to
the community. Folie d dettx is a condition in which one patient, usually a paranoic,
persuades another with whom he or she is very intimate of the reality of the sappoeed
plot against their lives or characters. The second patient, sometimes called the
passive element, is then insane, but is more likely to recover. In true paranoia there
is no recovery.

VL Dementia PrsBCOz. — This is a process of mental dissolution, appearing in persons
predisposed to this form of insanity, usually between the ages of fifteen and thirty
years. It comprises about one-eighth of all the admissions to asylums (Stoddart).
A history of some form of insanity, often of dementia prsdcox, in the family is the
rule, and the patient often shows one or more stigmata of degeneration — e.^., defor-
mities of the ears. The general health is poor ; appetite is lost, and constipation and
amenorrhosa are usual. The forehead is markedly wrinkled, far more than in m^an-
cholia ; occipital headache is often complained of, and the tendon reflexes are apt
to bo exaggerated. These pass off as the case becomes chronic and gains flesh and
bodily health under institutional treatment. The usual mental state is one of com-
plete indifference to the surroundings. There is often present one of the following
symptoms : Flexibilitas cerea, a condition on which the limbs remain for a long time
in any position in which they are placed ; Eohopraxia and Echolalia, in which the
actions or words of bystanders are imitated although questions are not lepHed to ;
Catatonia, in which the patient stands all day in one position unless he is disturbed ;
or Negativism, a condition in which the patient does the exact opposite of anything
that is required. There are many other disorders of conduct almost pathognomonic
of Dementia prsBcox, but for these the reader must consult one of the larger textbooks
on Insanity. The disease is incurable except in very rare instances.

VU. Epileptic Insanity. — About 10 per cent, of epileptics become so far unmanageable
as to be regarded as insane. The mental aberration may be (1) pre-paroxjrsmal. (2)
post-paroxysmal, (3) associated with petit mal only or as an epileptic equivalent, or
(4) a general mental deterioration.

VIII. Hyiterioal Insanity. — The mental perversions to which hysterical subjects
are occasionally liable are (1) emotional states ; (2) hystero-epilepey with insanity ;
(3) ecstasy ; (4) catalepsy ; and (5) trance. The first is an emotional condition often
of a religious kind — a religious veneration for the curate, for instance. The patients
are rarely or never suicidal or melancholic, though they may be passionate, mendacious,
misohiovous, crafty, noisy (screaming and singing hymns), and given to various kinds
of movement, such as hammering and dancing, or to the striking of attitudes (as in
ecstasy). Perversion of the tastes and the appetite and a general capricionsness are
very characteristio.

§ 642 ] OTHER SPECIAL TYPES OF INSANITY 761

Cues of the class under oonsideration are relatively frequent, and in general terms
the Prognosis of such cases is more favourable than many other forms of insanity,
especially if no hereditary mental taint exists, and due skill and judgment are em-
ployed in their treatment. In the TreeUmerU of these hysterical mental affections we
should, as far as possible, avoid putting them to bed, for complete want of will-
that is, lack of energy and initiative — is a characteristic feature, and they will soon
become bedridden. Change of environment, interests in life, and judicious com-
panions are the central points. It is seldom necessary to send them to an asylum.
Artificial feeding may be required, but should be discontinued as soon as possible.
Savage suggests adding salt to create an artificial thirst, and then placing fluid nourish-
ment in the way of the patient when, as sometimes happens, she is too lazy to feed
herself. Laziness leads to dirty habits and the passing of faeces in the bed. We
should look out for tubercle in these cases. Organic disease of the brain has sometimes
been found.

IX. Moral InMnity is recognised by some as a special form of insanity, in which
the mental disorder consists principally, and sometimes solely, of a marked deflection
from the normal standard of morality. The intelleot and the will may be normal, and
the emotions under control. In the adult, moral and ethical perversions occur (1)
very frequently as an early phcue of G. P. I., and many other forms of insanity, for,
as Esquirol remarked, moral alienation is but the " first step to madness.'* (2) It is
also met with in the adult after recovery from an attack of mania or other mental
disorder. The patient, especially if young, is frequently left with a sort of moral
scar, and the lower or animal side becomes prominent. (3) Occasionally one finds
in adults a moral defect as a stibstantive condition without previous insanity and
without any other mental defect. But often the childhood of such patients presented
some similar defect in a less degree, for the condition is more frequently hereditary
and congenital. Kleptomania (in which the patient is afflicted with an irresiBtible
impulse to thieve) belongs to this class. Other patients have irresistible erotic or
amorous tendencies, and others have a tendency to unnecessary exaggeration and
l3ring. Dipsomania is a paroxysmal, irresistible craving for drink. (4) Moral insanity
as a substantive disorder is chiefly met with in children, particularly those of alcoholic,
insane, or epileptic parents. In early childhood they may be perverse, mischievous,
cruel, untruthful, or thieving. They are often precocious, and they may even be
intellectually gifted. Nevertheless, such childr^ generally need incarceration in
course of time, if they do not find their way into prison. It seems probable that a large
proportion of the criminal convictions among the children of the lower orders are
subjects of this malady. The condition, as a rule, is incurable, unless by educational
and disciplinary measures.

X. Obtefsional and Impnlfive Insanity. — ^This is always due to a psychopathic
heredity. Patients suffer from weak will power (abulia) and are beset with obses-
sional or imperative ideas, or are haunted by dreads and fears of doing something
they are anxious to avoid.

XI. Alcoholic Insanity. — Alcohol is generally accorded the chief place in the causa-
tion of insanity. It may result in two special forms : (a) delirium tremens, and
(6) alcoholic dementia ; it may also result in (c) delusional and other forms of insanity.;

XII. Syphilitic Insanity. — (a) After contracting, or running the risk of contracting,'
this loathsome disease it will prey on the minds of some persons to such an extent
as to produce an extreme degree of hypochondriasis, to which the term syphilophobia
is aptly applied. In every symptom, normal or abnormal, they see the disease.
The term is also applied to certain patients who have a morbid fear of contracting
syphilis, which becomes an obsession with them. (&) Syphilitic endarteritis may lead
to a dementia indistinguishable from senile dementia except by the age of the patient.
Various forms of mania and melancholia may also be associated with arterial and gum-
matous lesions, or with concurrent cachexia, (c) General paralysis of the insane is a
parasyphilitio process (f 541).

XIII. Pnerperal Insanity is a generic term for the mental disorder which arises
under three different conditions, (a) The mental perversion which arises during
'pregnancy is generally a form of mdanchdlia, and varies in degree from a simple
exaggeration of the morbid longings and perverted tastes which are more or less

762 THE NERVOUS 8 Y8TEM [ f Mt

usual during gestation to melancholia of a pronounced type, accompanied, perhaps,
by delusions and a suicidal tendency. It is not generally serious unless heredity is
in operation, and usually disappears after the confinement. (6) Puerperal mania
(or puerperal insanity proper) arises usually between the first and fourth week after
delivery, coming on usually suddenly with maniacal symptoms, (c) The ioBanity
of Lactation, or post-puerperal insanity, is a form of melancholia which arises during
the first two or three months, or any time during the first twelve months after oonfine-
ment. All three forms are apt to recur in succeeding pregnancies, but unless there
is a hereditary taint of insanity the prognosis is good for recovery. Abundant food
and removal from home are indicated, and special measures should be directed to meet
the tendency to suicide or infanticide which is frequently present even in the mildeat
oases, and gives no indication of its presence until some untoward event occurs.

XIV. Oatslepiy (jcaraXe^i;, a seizure or attack) may be defined as a state ol
stupor in which the patient is deprived of sensation and voluntary motion, in which
the limbs remain in any position in which they are put (flexibilitas oerea). The patient
may appear, but it does not follow that she is, unconscious of her surroundings. The
eyes may be open, but she appears totally oblivious to all the outside world, and she
may lie for hours, or days, perhaps, passing her motions under her. These patients
are nearly always of the female sex, and are invariably the subjects of some other
hysterical manifestations, to which category, indeed, the condition belongs. Some-
times these cataleptic attacks are ushered in by hysterical convulsions or a hysterical
faint. They are usually determined by a fright or some emotional storm.

XV. Trance is a condition of stupor allied to catalepsy, in which the limbs are either
rigid, or, more usually, flaccid, and lacking the feature of remaining in any one position
in which they are placed. The patient may remain for weeks or months in what
seems to be a faint, taking no notice, eating no food, making no movement, and
scarcely breathing ; though here again she may not be as unconscious as she seems.
The pulse is hardly perceptible at the wrist, and unless the patient is forcibly fed she
may ultimately die ; but it is siirprising the length of time she may live with hardly
any nourishment.

§ 648. PrognofiB and Treatment of insanity in general. — The Course and Ptognom
in several of the various forms of insanity have been referred to. In general termfl
the chief points on which the prospect of recovery depends are (1) the absence oi
heredity, especially direct heredity ; (2) the rate of onset of the attack, being more
favourable in a rapid than a slow, insidious advent ; (3) the duration of the attack
before the patient comes imder treatment ; and (4) the kind of insanity present.

Prospect of Recovery in Chronic Mental Disorders.

Qood, Moderate, Bad,

Hysteria. Delusional. G. P. I.

Alcoholic. Mania. Moral insanity.

Syphilitic (mostly). Melancholia. Dementia.

Puerperal. I

The Treatment of insanity in detail has been referred to under the different forms,
but the general principles resolve themselves into four indications: (1) Feeding;
(2) change of environment ; (3) placing under restraint ; and (4) treatment of any
physical defect discoverable. Hypnotism (as below) is available for some of the
slighter cases, especially where alcoholism is in question.

The question of removal to an asylum depends on many things, chiefly (i.) the
manageability of the patient ; (ii.) the means at homo for control ; and (iii.) the charac-
ter of the mental disorder and its potentiality for homicide or suicide.

Any mental patient, however mad, can be taken care of by his or her relatione
\cithout certification, provided it is done without payment or restraint, they being
responsible for the patient's safety.

5648] PROGNOSIS AND TREATMENT OF INSANITY 763

Cases of slight eooentrioity and uncertifiable mental aberration may be received
into the hous^ of a medical man or other householder for payment ; but directly a
case becomes certifiable (in the opinion of the Commissioners) it must be placed under
certificate. The penalties for breach of this are very heavy. No medical man or
other householder may retain in his house more than one certified patient at a time
without special permission from the Commissioners.

A mental patient can be received at a private asylum as a voluntary boarder tvUhout
certification if the patient writes a letter to the Commissioners in Lunacy (Victoria
Street, Ix)ndon, S.W.) stating that he wishes to go there as a voluntary boarder, and
his medical attendant reports he is a suitable case.

Procednre lor Removal of Lunatici and Alleged Lnnatici.— The procedure for
removal is somewhat intricate, and it is useful to remember that the relieving officer
of the parish is a most convenient person to apply to, bearing in mind, however, that
it is no part of his duty to undertake private cases, but that, nevertheless, if he be
approached with due regard to the importance of his office, he may save those con-
cerned a great deal of trouble, and supply them with all the necessary forms and
particulars as to modes of procedure. He is also m constant relation with the lunacy
justices.

A person doomed to bo a lunatic, and found loandering at large not under proper
care, can be apprehended by a " constable, relieving officer, or overseer " of the
parish, and taken to the workhouse. Any person, either pauper or lum-jfaupert deemed
to bo a person of unsound mind can. for his own safety or that of others, be removed
from a dwelling-house by a relieving officer to the workhouse. In either case the
patient can be detained there for throe days upon the certificate of such constable or
relievmg officer, and, further, upon the certificate of the medical officer of the work-
house, for a total of fourteen days. Meantime the procedure under No. 3 (c) below
can be instituted. This method is now often utilised for persons in all classes of life
who are dangerous and away from their friends.

la private cases the urgency order (1, below) can be used in urgent oases. This
holds good for three days from date of signature ; if not urgent (2) is the usual method.

All the different forms necessary are procurable from Shaw, Fetter Lane, London,
or. as previously mentioned, from the relieving officer.

A patient can be removed to an asylum in England or Wales in five ways :

(1) Under an Urgency order signed by a relation (or guardian) and one doctor.

(2) Under a Reception order of a Justice obtained by petition of relative on two
doctors* certificates (used also for certification in a case for single care).

(3) Under a Summary Reception order of a Justice,

(o) On information from the police or relieving officer that a non-pauper
is cruelly treated or neglected, a Justice calls in two doctors, who
certify insanity.

(6) On information from the police or relieving officer that any person,
pauper or not, is wandering at large deemed to be a lunatic, a Justice
calls in one doctor who certifies insanity.

(c) On information from the relieving officer that a x>auper is deemed to be
a lunatic, a Justice calls in one doctor who certifies insanity.

(4) Under an order after Inquisition, being a written authority from the " Com-

mittee " of the person, together with an office copy of the order of the
Court of Chancery appointing the " Committee." The " committee " is a
legal phrase for the guardian appointed by the court.

(5) Under a Reception order by two Commissioners (rarely done), who call in a

doctor who certifies insanity.

Idiots and imbeciles (from early life) can bo removed to an idiot or imbecile asylum
on one medical certificate and a statement by a relative.

The procedure in Ireland and Scotland is somewhat different.

Testamentary Capacity.— The intricate technicalities of the lunacy law cannot be
entered upon here, but a knowledge of what constitutes the testamentary capacity
of a patient is of groat importance to the practitioner, because it is often on his evidence
that courts of justice decide such matters. The testamentary capacity of a person of
unsound mind depends practically on three questions :

764 THE NERVOUS SYSTEM [ f 544

1. Did he at the time undeistand the nature of a will and ite eifeota, and did lie

anderatand the extent of the property of which he was disposing ?

2. Did he provide for his relatives, or, if not, why did he leave them out ?

3. Had he any delusion bearing on testamentary matters ?

If these questions can be satisfactorily answered and proven, ttio will is valid, how-
ever eccentric the patient may have been, or even if he was at the timo a cer^6ed
lunatic. The fourth question — ^undue influence — ^is a non-modical question.

f 544. Hypnotism. — Hypnosis may be defined as a condition resembUng sleep.
in which the subject's capability to receive and act upon suggestions is greatly in-
creased. This increased suggestibility is made use of by the operator for the im-
planting of new and healthy conceptions and the removal of morbid ideas, the object
being to influence the body though the mind. It is worthy of study both from a
psychological and a medical point of view. It explains many of the cures performed
at Lourdes and other shrines, and by faith-healers in all parts of the world.

Bemheim asserts that 80 per cent, of his hospital patients are hypnotisable t-o the
extent of somnambulism, characterised by amnesia on waking ; in his private praetioe
the proportion was much less. Dr. Uoyd Tuckey and the author, in the oouTBe of
some experiments at Paddington Infirmary, estimated that only about 5 per cent
of the patients there were hypnotisable to that degree. Ansemic young women are
perhaps the most easily hypnotised, but strong and healthy men are often sosoeptible.
and it is now established that people in whom there is not the faintest suspicion of
hysteria are subject to hypnotic influence. Wingfield found the imdergradnates at
Cambridge particularly good subjects, and soldiers and others accustomed to respond
to the word of command are very amenable to hypnotic suggestion. Children, too.
are good subjects when able to understand what is expected of them, whereas the
insane and imbecile are generally unhypnotisable, and hysterical women are by no
means the best subjects. It is only by trial one can determine whether a person is
hypnotisable.

There are various methods of hypnotising which are easily acquired. The patient
should be put at his ease and seated in a comfortable chair. He is made to relax
all his muscles and to fix his gaze on a bright object held about 12 inches above the
eyes, so as to cause a slight strain and convergent strabismus. This is the method
of "fascination'* (Braid), and susceptible persons will faU into a cataleptic or
sonmambulic condition when submitted to it without further procedure. In the
method of '* persuasion " hypnosis is induced by verbal suggestion of sleepy sensationa.
such as heaviness of the eyelids and limbs, and increasing torpor of mind and body.
" Passes," as the mesmerists called them, made by passing the hands, fingers
extended, about ^ inch from the face so as to create a slight draught of air, are often
helpful in producing and deepening hypnosis. Whatever method is used, the rationaU
is the same — ^it consists of monotonous stimulation of one or more senses, with
corresponding inhibition of others, leading to a condition of altered consciousness, in
which organic functions as well as mental states become more under the control of
the operator. Some hold that the deeper the hypnosis, the greater the effiect of
suggestion ; but good therapeutic results are obtainable when only a slight drowsiness
is produced. The patient should bo allowed to rest quietly for half an hour, and shonM
be told to awake without shock or feeling of discomfort at the expiration of that time,
either spontaneously or on a given signal. The suggestions should be given in an authori-
tative and impressive manner, and may be accompanied by manipulation of the affected
part as practised by Braid. They are directed towards the removal of pain, spasm.
and other symptoms, and the re-establishment of normal functions. Such suggestions
often act immediately, and the action in successful cases is continuous and sustained.

Hypnotism should be used only by medical men, and with proper precautions. The
consent of the patient and his friends should be obtained, and a third person should be
present during the operation. In competent hands no bad effects result from its
employment even over prolonged periods, but much evil, moral and physical, might
follow the abuse or misuse of this powerful agent. Its use for purposes of public
exhibition should be forbidden by law.

Uses, — ^Therapeutically, hypnotism has been employed to relieve pain, to procure
sleep and rest, to remove delusions and obsessent ideas — e,g., agoraphobia — to

§ 545 ] MENTAL DEFIOIENOY IN ADOLESCENCE 765

cure the effects of grief and shook, to reform alcoholics and moral perverts, to
cure various neuroses, such as nocturnal enuresis, writer's cramp, to relieve various
hysterical manifestations such as anaesthesia, attacks, and paralysis. Witterstrand,
of Stockholm, claims to have cured many oases of epilepsy by keeping patients
in a state of profound hypnosis for three weeks continuously. In exceptional
cases hypnotism has been employed as an anaesthetic in surgical and midwifery
practice.^

§545. Mental Deficiency in Adolescence (ten to twenty years) may
(1) consist occasionally of one of the chronic mental disorders of adults
previously described, and especially the dementia prsecox and moral
INSANITY described in § 542 ; or (2) it may be a sequence of either of the
two groups below (congenital and non-congenital mental deficiency of
childhood) (see § 546). (3) There is also a primary mental deficiency
inherent in the individual, and manifested for the first time in adolescence,
and it is this last cl^s with which we are now concerned ; it includes the
" borderland cases," and constitutes at once the puzzle of the alienist and
the trial and burden of relatives and guardians.

8ympU>m8. — Various kinds and degrees of defect may be met with. It is nearly
always between the ages of ten and twenty that such oases come under notice for the
first time, sometimes because " they will do stupid things," sometimes for ** ro-
mancing *' or lying, sometimes because they do not learn as rapidly, as others, or " are
not so bright " ; sometimes because they are unruly, or have taken to drink or other
vices. In the last-named case, when they have a moral obliquity, they may be
possessed of brilliant intellectual gifts, but more often there is an aU-round deficiency,
and they are and remain childish aU their lives. This deficiency leads them to consort
with all sorts and conditions of men and women, whose habits and language they
quickly imitate ; if sent for a sea voyage, they are generaUy to be found in the fore-
castle or steward's pantry, and rapidly assume the indelicate language of the seafaring
man. Their parents expostulate with them, and they promise, and do try, to avoid
repeating the offences, but they soon break out again. Much trouble accrues to the
parents and guardians of such persons to keep them, when belonging to the well-to-do
classes of life, from squandering a fortune, forming an ill-judged liaison, or getting into
other and worse troubles, and when belonging to the lower classes, to keep them out
of prison.

Causes. — In nearly all such cases there is a neuropathic family history on one or
both sides. A few cases can be traced to some of the causes of acquired mental defi-
ciency previously mentioned. Inbreeding, such as occurs in the aristocracy, may be
a contributory cause. The condition would naturally be aggravated by faulty
education and mode of life, but without the hereditary and inherent mental defect it
cannot be produced.

The Treatment is a question of careful training and education, and a good deal can
be accomplished if no expense is spared. It is always best, I am sure, to remove these
cases from home, for nearly always a state of friction arises between the girl or youth
and one or other parent, which is detrimental to their progress. If the patient is
liable to outbursts of passion, these must be gently curbed, and the system of education
made attractive by utilising any particular taste which they have. The amount of
improvement which such cases are capable of depends upon the possibility of fixing
the attention, and this depends largely on their having some taste which can be so
utilised, such, for instance, as music. The possibility of errors of refraction may be
remembered, as in the cases quoted on p. 769.

^ Those who wish to study the subject of hypnotism more closely should consult
'* Per^chotherapeutics ; or, Treatment by Hypnotism and Suggestion/' by Dr. Lloyd
Tuokey, 6th edition, London, 1907, Bailliere, Tindall and C^x ; " Hypnotism : Its
History, Practice, and Theory," by Dr. Milne BramweU ; or the classical works of
Charcot and Bemheim.

766 THE NERVOtJS SYSTEM I §

§ 546. Mental Defects in Children under Ten are very different to the

mental disorders of adults. Moral perversion or insanity, as alrcadj
mentioned (§ 542), is not infrequent, but mania, melancholia, and other
adult varieties are extremely rare. Mental deficiency as a whole is the
characteristic of this age period, and this is what will concern us now.
It may be congenital — i,e., due to ante-natal causes — or acquired (non-
congenital) — i.e., due to causes arising after birth.

The Symptoms and causes of these two groups differ considerably. In both varietaes
the children are " backward/* deficient in all the faculties of the mind in grv^ter ar
less degree ; they carry evidences of this in their manner and behaviour, and some-
times, but not always, in their face. Congenital cases nearly always present aomt
well-marked alteraiion in the f acted or cranial and bodily conformalion, and very often
they are dwarfed in body as well as in mind. Children belonging to the non-ookoksi-
TAL class of mental deficiency do not present these physical cdterations ; their oxpreflson
is bright, their cranium and face natural, their limbs well made, and, excepting in the
paralytic class, they can generally walk and run well. Unfortunately, they are also
distinguished from the congenital class by a mobility and restlessness which is an
indication of the difficulty of fixing their attention, and therefore of teaching them.
They may also be distinguished from the congenital oases by a history of their having
been mentally sound at birth and for some years afterwards, but among the Iowc«
orders a history of any diagnostic value is often wanting.

The practical point to ascertain in all cases of mental deficiency in childhood is
their teachability, and this depends on two questions : (1) Can their attention be
attracted and fixed ? and (2) Are they imitative ? (3) Their facial and bodily con-
formation should be observed ; (4) the history or evidences of paralysis noted ; and
(5) if they have been to a Council School in England, the standard they have reached
— the average in the infants' school is anything under five years ; in Standard I..
seven to eight years, with an increment of one year for each succeeding standard.
Standard VII. being reached by normal children at thirteen or fourteen.

The oongenital varietiei of mental deficiency in childhood (idiocy) date from birth.
and the children generally present evidences in the facial and cranial conformatjon
as well as in the mind. In a good many of these cases the palate is too hi^i. or
V-shaped, too narrow from side to side, or otherwise deformed. The palate described
by Sir T. Qouston. and called by him the " neurotic palate," is one midway between
the normal palate and the V-shaped palate, and is found in persons of nervons tem-
perament, who are liable to hysteria, neuralgia, and migraine. Dr. Fletcher Beach
found that out of 700 feeble-minded children 28 per cent, had V-shaped or otherwise
deformed palates, and 60 per cent, had neurotic palates. On the other hand, a high
or V-shaped palate does not necessarily imply congenital deficiency, as was at first
thought.

The Vabibtibs of Idiocy (Congenital Mental Defect in Childhood), as given by
Dr. Fletcher Beach, ^ are six in number.

1. Simple Congenital Idiocy includes children without any dbvioua abnormality of
the cranium or limbs, only in the face or palate (supra). In some the fiaoial expression
may be faiiiy intelligent, but most of the lower grade present an animal expression,
thick lips, pug-nose, large coarse ears, broad, thick, depressed bridge of nose, narrow
or hairy forehead, and underhung jaw.

2. The Mongol or Chinese type of congenital deficiency is so called from the resem-
blance of the face to that of the Chinese, the palpebral fissures sloping downwards and
iliwards. With flat face, flat back to the head, and constant protrusions of the tongue,
this form of idiocy presents an unmistakable physiognomy. The fingers also are
stunted and the little fingers incurved. Congenital heart disease occurs in about
30 per cent. They may be regarded as *' imfinished *' children, as they are often
bom of mothers who have suffered from continued ill-health during pregnancy ; some-

* Clinical Journal, August 4, 1897 ; and " The Treatment and Education of Mentally
Feeble Children/* Fletcher Beach, 1895, Churchill, London.

§ 546 ] MENTAL DEFECTS IN OHILDREN UNDER TEN 767

times they are the yonngcst of a large family, or bom of parents advanced in life.
These children are imitative, and therefore educablo to a limitod extent, but they make
no progress beyond a certain point.

3. Microcephalic idiocy includes children whoso heads are smaller in circumference
than normal, which averages about 19 inches. The head may measure 17, 15, or even
12 inches ; the forehead is narrow, and slopes backwards, corresponding with the
deficiency of the frontal development of the brain. The features are frequently
normal, eyes large, and nose aquiline. These children rarely make much improve-
ment, for they have but little power of attention, though some of them are imitative.
The question of craniectomy was raised Rome years ago in connection with these oases,
as the small size of the brain was thought to be due to premature union of the cranial
sutures, but this is now known to bo incorrect.

4. Scapho-Cephaly is so called from the boat-shaped character of the head, the
antero-posterior being considerably longer than the transverse diameter. Mental
defect is not necessarily associated with this cranial conformation. But too much
dependence must not be placed on the shape of the head, unless it is combined with
mental defect. The children are sometimes deficient in intellect, but teachable.

5. Hydrocephalic idiocy occurs in so me of the children bom with hydrocephalus. Some
retain their intelligence for a considerable while, but usually they drift into imbecility.

6. In Paralytic oases the child has had hemiplegia, paraplegia, or diplegia, dating
from birth. The paralysis may be due to some inflammatory condition of the mem-
branes in utero, or pressure or injury before or at the time of birth (birth palsy, q.v,).
Cerebral atrophy, congenital malformations, and other lesions have been found. Men-
tally these children generally make good progress under education, but physically
little can be done for them.

7. In Sporadic and endemic Cretinism the markedly stunted growth is the most
characteristic feature. The head is usually large, flat at the top, spread out at the
sides (Fig. 6, § 19). Hair coarse and dry, like that of a horse's tail. Voice hoarse
and squeaky. Speech generally limited to a few words, and often monosyllabic.
Their temperament is placid and good-natured. Under treatment by thyroid gland
or extract these cases make very remarkable progress, as in the two illustrations given.
The treatment must be continued during the patient's lifetime, otherwise they relapse
into their old condition.

Causes of Oonoenital Mental Dbfioibnoy in children. — a. Causes acting in the
parents before birth (heredity) occupy a very prominent place. Beach and Shuttle-
worth have exhaustively investigated this question in 2,400 cases. Abnormal condi-
tions in the mother during pregnancy account for as much as 29 per cent., among
which may be mentioned injuries, worry, anxiety, fright, or illness. Phthisis in the
parents accounts for 28 per cent., insanity and imbecility 21 per cent., epilepsy and
other neuroses 20 per cent., and intemperance in the parents 16 per cent. Consan-
guinity acted as a cause in only 4 per cent., even when consanguinity in the grand-
parents was taken into account. This is somewhat at variance with the generally
supposed evil of marriage between blood relations, but it is a fact about which there
seems no doubt, and Dr. Beach adds : '* Even in those cases where consanguinity was
present there were other hereditary tendencies, of themselves quite sufficient to produce
the affection (congenital mental deficiency) without the presence of consanguinity."
Syphilis in the parents was responsible for only 1'7, the effect of syphilis in the parents
apparently being not so much the procreation of idiots as of children apparently
healthy at birth whose nervous systems break down at the age of puberty.

/3. Among the causes acting at the time of birth prolonged or tedious parturition is
undoubtedly the most potent. It is sometimes supposed that injury by forceps is a
potent cause of the production of congenital mental deficiency, but it is worthy of note
that in only 3 per cent, of Beach and Shuttleworth*s oases was there a history of
delivery by forceps. His facts go to show that it is far better to put on the forceps
early than to allow labour to be prolonged indefinitely. Such prolongation leads to
great compression of the cranium, the brain being crushed, distorted, and otherwise
injured. Such children when bom are very often in an absolutely helpless condition.
Others are subject to convulsions, and when death ensues, meningeal hspmorrhage
and cortical laceration are very often found.

768 THE NERVOUS SYSTEM [ § Mi

AoQuired (or non-congenital) mental deficiency in children under ten ia rarely difficoh
to differentiate from the congonital deficiency (vide supra). The varieties depend
upon the causes. Among the Causes infantile convulsions was in operation in 27 "pft
cent, of the 2,400 cases which Dr. Beach collected, epilepsy and other cerebral affectiooA
in 8 per cent., head injury in 6 per cent., fright or shock in 3 per cent., febrile disnaaa
such as scarlatina, measles, whooping cough, enteric, small-pox in 6 per cent., &nd over-
pressure at school was only mentioned in 0*16 per cent.

1. Infantile Convulsions, if only occurring once or twice, may have no evil remilt.
but if continued for some time throughout the early months of life, they (peneraOj
result in a certain degree of weakmindedness. Many such cases occur in the childrre
3f insand or epileptic parents. They generally make little or no improvement, And drift
into imbecility.

2. Epilepsy, as a rule, does not commence until after ten years of age. but in some
rare casos where it starts quite early in life it is attended with marked mental deficiency.
although the fits may be few in number. Some cases improve if the fite cease, bat
mostly they go from bad to worse. Infontile convulsions cease before two jrear?,
epilepsy never occurs till after two, and very rarely till after fourteen years.

3. In Paralytic Cases the mental deficiency is associated with hemiplegia, and very
often epileptiform seizures (q.v.) which have started after birth. They are mostly doe
to cerebral hsBmorrhage and the scar which results.

4. Traumatic Causes. — Injuries to the head in childhood frequently result in mental
deficiency. The injury, as previously mentioned, may have occurred during child-
birth (compare j3, p. 767), though the symptoms may not have arisen until later.
But quite as often the traumatism occurs after birth, and its history is a little diffienlt
to make out. I frequently see mentally defective children in the out-patient room
in whom careful inquiry reveals the history of a fall from a perambulator or cot, which
had been disregarded by the mother. One should always suspect an injury (perhapt
concealed by the nurse) when the mental symptoms are associated with spastic hemi-
plegia. But very often there is no sign of paralysis or scar on the head, and the fits
or mental defect from which the patient suffers did not supervene till many months
cr a year or so after the injury, being, in fact, due to the cerebral scar which results.

5. InflammcUory Cases. — The acute specific fevers, meningitis, and other infiam-
matory conditions may be followed by mental deficiency. It seems to me probaUe
that most of these cases are due to concurrent or consequent inflammation of the
brain or its membranes. The mental symptoms do not necessarily follow directly
after the illness which has caused the mental defect, as in the case about to bo men-
tioned, and therefore we may have only the history to rely upon. These casos are
among the worst which we have to deal with. They are analogous to cases of mania
occurring in the adult, excepting in their imiversally unfavourable course. In
October, 1897, a little girl, mi. three and a half years, was brought to me by her
mother. She ran perpetually around the room from object to object, resting her
attention on nothing for more than a second or two at a time, taking no notice of any-
body. The mother said she was excitable at night and often mischievous. The birth
had been natural, and the child normal at birth and up to the age of two years. Theii
she was laid up with a feverish attack, which was called '* influenza,*' attended by vezy
severe headache, with which she was ill for several weeks. She recovered completely,
and it was not until the age of three that she began to be unmanageable and destructive,
and the present condition slowly supervened.

6. Hypertrophy of the Brain is included by Dr. Beach imder the heading of inflam-
matory cases, because the post-mortem appearances of patients who died of this
disease under his care showed that there was, or had been, chronic inflammation of
the brain. In these cases both the brain and the skull are enlarged, the shape of the
head being more of a square than in hydrocephalus.

7. Hereditary Syphilis. — Among the symptoms of this protean disorder is mental
.deficiency in childhood. It does not seem to affect the brain in infancy or early
childhood, but about the period of the second dentition, or between that and the
time of puberty, the nervous system sometimes shows signs of progresBive degenera-
tion. Sometimes this is manifested by disseminated sclerosis or other spinal disease,
sometimes only by a steady deterioration of the mind.

§ 647 ] MENTAL DEFECTS IN OHILDBEN VNDER TEN 769

8. Reflex Causes, — Mental symptoms of a pronounced kind arise in association with
asthenopia in children. Two little girls, aged six and thirteen years, were brought to
me for great despondency, and crying without cause. The mother of each stated
the child was constantly crying without a reason, and was constantly saying that her
parents and others were against her and hard on her. No heredity was in operation.
The vision was found by my colleague, Mr. Work Dodd, to be six-twelfths and eight-
twelfths of normal, and on this being adequately corrected by glasses the mental
symptoms entirely disappeared.

9. Theoretically, it is possible for some of the forms of mental alienation met with
in adult life to appear in childhood, but mental disease practically only arises in child-
hood when one of the above causes is in operation.

The Prognosis of Aoqitibeb Mental Deficiency in childhood is always very grave.
Indeed, there are few cases where much improvement takes place when once the
deficiency is established. If the mental symptoms seem to have come to a standstill,
and the child is in any degree educable, something may be done in this direction ; but,
as a rule, less can be done for acquired cases than for congenital, and their tendency
is to get worse.

In the Treatment of Mental Deficibnoy in Childhood, whether congenital
or acquibed, a certam amount can be done by education and discipline. The first
and fundamental principle is to remove the child from ita home and from the sur-
rounding conditions which have been unconsciously adapted to its defective habits*
The second point is to fix the child's attention, and this can best be done by employing
music, pictures, and other things which please and attract the child. It may be
taken as a general principle that the educability of a child — ^that is to say, the prospect
of recovery — depends entirely upon the facUity with which the attention can be
attracted and the efficiency with which it can be retained when once secured. The
shape of the head and aspect of the face cannot be relied upon ; the brightest looking
children are often the most volatile. On the other hand, the dull-looking children
who take an interest in their work will make more progress. As a rule, the prognosis
is much worse in irritable, restless cases than in quiet cases. It is usual to commence
with the education of the senses — ^touch first, then sight, hearing, taste, and smell.
Speech also has to be educated by means of speech drill. Any vicious habits must
be gently corrected, and punctuality and discipline enforced. Li&ter on, perseverance,
and ideas of justice, duty, self-reliance, prudence, and forethought have to be incul-
cated. The progress of any case under treatment depends very much on the age at
which it is commenced. It should always be begun as early as possible, i^nd the idea
which some mothers have of the symptoms passing off at seven or fourteen by an abrupt
change from mental enfeeblement to mental brightness should be met and combated
as wholly fallacious, and very damaging to the prospects of success.

GROUP IIL INTRACRANIAL INFLAMMATION.

§ 547. Pyrexial disorders of the nervous system are not numerous, and

are practically confijied — if acute anterior poliomyelitis and certain

exceptional cases of cerebral abscess and cerebral hsemorrhage be omitted —

to acute inflammation of the meninges. They consist of the following

intracranial inflammatory conditions, all of which present cerebral symptoms

%oiih fyrexia and its attendant symptoms. The onset in most is acute,

though in some it is insidious.

I. Tuberculous meningitis (§ 548).

IL Acute meningitis (§ 549).

III. Post-basic meningitis (§ 549).

IV. Epidemic oerebro-spinal meningitis (§ 373).
y. Intracranial abscess (§ 560).

VI. Sinus thrombosis (especially septic thrombosis) ({ 551).
VII. Hiemorrhage. chronic degenerative diseases, etc.

770 THE NERVOUS SYSTEM [ §

Clikioal iNYBSTiaATiON. — 1. The cerdtral symptoms in intracranial ioflammataoa
may be grouped into those of irritation and compression. The 83miptoiiia of eortied
irritation which are the most usual, especially in the early stages, consist of headache.
vomiting, tonic or clonic spasms or convulsions, sleeplessness, restleeaneflB, delirian.
quick pulse, and contracted pupils. The symptoms of compression, which vsuafly
ensue later, are mental dulness. paralysis of the limbs and cranial nerves, a aiow 6dl
pulse, dilated or unequal pupils, and stupor passing on to coma. The eaiiicr or
irritative stages may have to be diagnosed from other causes of convulsions ({ 507) ;
the later compression stage from the typhoid state (§ 346) or coma (§ 590).

2. The scalp and cranial hones should be examined for any swelling or tendemes
on percussion — eg,, any oedema (siniis thrombosis), erysipelas or Pott*s pu£^ tumov
(an OBdematous swelling of the scalp which is usually a sign of subcranial extra-dunl
abscess in that situation). When there has been a vxmnd of the scalp, the skin maj
have healed up externally though pus has formed beneath, and the infective prodneto
carried along the perivascular deaths or lymphatics into the skull. But the patitiA
may go about for days or weeks before 83rmptoms of intracranial inflammatioii |MtsuBt
themselves. ,

3. The ear and sinuses near it, the nose, and the pharynx should also be carelslly
examined for any discharge or signs of disease.

4. The cranial nerves need to be examined severally (§ 608 et seq.), TnfJaminatitw.
like tuberculous meningitis, which has a predilection for the base, neariy always
reveals cranial paralysis at some time ; but those which affect the convexitj of the
brain, such as simple meningitis, give rise rather to convulsions.

5. The lungs and other organs should be examined. Many cases of taberenlosi
meningitis are secondary to tuberculosis of the lungs or peritoneum.

6. The age and history of the patient, especially as regards any previous otcMrhAa,
may be noted. Acute meningitis may occur at any age, and runs a course of abssi
two days to two weeks ; tuberculous meningitis chiefly afiiects childrMi, and nms a
course of two weeks to two months (including premonitory stage) ; post-baaio meniB-
gitis is almost confined to infants under one year, and runs a prolonged and indefinite
course.

7. The temperature should be carefully investigated, and a chart obtained. Divnial
intermissions suggest tuberculous meningitis (§ 648). A nondescript or oontiniied
temperature suggests acute meningitis (§ 649). The temperature falling after a few
days of initial rise and becoming subnormal suggests cerebral abscess (§ 550). \^^de
and irregular intermissions suggest septic sinus thrombosis (§ 651).

8. Lumbar puncture is a valuable aid both to diagnosis (pp. 897 and 900) and
treatment (§ 626).

§ 548* I. Taberonlous Meningitis* tuberculosis of the cerebral meninges^
is the commonest cause of intracranial inflammation in children. The
cerebral pia mater, especially at the base and in the Sylvian fissure, be-
comes studded with grey miliary tubercles. It is more frequent in
children, and in the male sex. Tuberculous meningitis may (i.) supervene
in a case of tuberculosis elsewhere, of which symptoms have existed
previously ; (ii.) it may be ushered in suddenly with vomiting and eon-
vulsions in a child previously in good health ; or (iii.) it may come on
insidiously as a primary affection of the meninges, with a long prodromal
period.

The Symptoms are usually insidious and variable. There is a prodromal
and three other stages, the latter running a course of two or three weeks,
and passing imperceptibly into each other. In the prodromal stage,
which may last a considerable time, the child gets thinner, loses its
appetite, is peevish and listless but with intervals of brightness, when tlie
mother thinks it b becoming well again. Intermittent pyrexia may be

§548] TUBERCULOUS MENINGITIS 771

revealed from time to time. (1) The irritative stage is ushered in, very
often suddenly, with (i.) severe headache, vomiting, or convulsions, and
there may be delirium, or the child may lie curled up, shrinking from light
or sound, (ii.) There is a moderate degree of fever, usually of a diumally
intermittent t3rpe. (iii.) The pulse is quick, and the pupils contracted,
(iv.) The head generally shows a characteristic retraction with rigidity
of the muscles of the neck, (v.) The abdomen is retracted. When
vomiting without diarrhoea is present in a child, tuberculous meningitis,
or other head mischief should be suspected, (vi.) The peculiar cry, known
as the " hydrocephalic cry," may accompany this stage of the diseasei
and last till the end. As a rule, the irritative stage lasts only a few days
to a week. (2) The compressian stage is announced by symptoms pointing
to paralysis of the cranial nerves as in all diseases situated chiefly at the
base of the skull, (i.) The pupils are unequal, and become dilated, and
strabismus is common owing to paralysis of the sixth or third nerves,
(ii.) The patient is drowsy, with slow pulse, which may be irregular, and
sighing respiration, (iii.) There is vaso-motor paralysis, indicated by the
red streak foUowing the track of the flnger-nail drawn along the skin. This
condition is known as the " t4che c6r6brale " (Trousseau), from the idea,
now known to be mistaken, that it was found only with cerebral lesions,
(iv.) Optic neuritis or tubercle of the choroid may develop. (3) The final
stage is marked by increasing irregularity and weakness of the pulse and
the respiration. The drowsiness passes into coma, and there is incon-
tinence of urine and fseces. Mucus gathers in the bronchial tubes, and
breathing is laboured, and often takes the Cheyne-Stokes form. Just at
the end the temperature may rapidly fall, or it may rise very high (106°
or 107° F.) and local paralyses — e,g,, of the arm or leg, or ptosis may occur,
with convulsions. This stage lasts only a few days.

Tuberctilous meningitU in adulta is often seoondary to tuberole in the lungs, abdo«
men, or elsewhere. It differs from the disease in children in : (1) The advent is most
insidious and prolonged. I once saw a typical example of this where headache and
intermitting pyrexia were the only symptoms for nine weeks. (2) Severe and per-
sistent headache with intermitting pyrexia are always very prominent features.
Hemiplegia, or, rather, hemiparesis, may be the earliest and principal symptom, and
aphaiUa is not infrequent ; while (3) optio neuritis, strabismus, or other evidence of
cranial nerve paralysis, such as facial paresis, or inability to swallow, are present as
in children. Vomiting and convulsions are rare. (4) The course lasts from five to
twelve or more weeks.

The Diagnosis of tuberculous meningitis may often be settled by limibar
puncture (pp. 897, 899, and § 626). Enteric fever, with head symptoms,
and no rash or diarrhoea, may for a week or longer be mistaken for menin-
gitis ; and, on the other hand, the meningitis which has little headache
may be mistaken for enteric fever. But the course of the disease and the
aid of the Widal reaction soon reveal its true nature. Any one of t^e
spedfio fevers may be ushered in with headache so severe as to give rise to
a suspicion of meningitis ; but in all such cases the headache ceases when
delirium begins. Irregularity in the breathing and the pulse, and

772 THE NERVOUS SYSTEM [ §

evidences of basal paralyses are conclusive signs of meningitis. Acute
meningitis is distinguished from the tuberculous variety by its rapid
course, which rarely exceeds a few days, by there being no basal paralyses,
and by the presence, perhaps, of a local cause, such as injury or otitis
media. A rapidly-growing tumour — e.g., tuberculous or gliomatous —
may simulate meningitis. Here the character of the optic neuritis present
aids diagnosis — if very intense, with swelling and haemorrhages, it is
probably due to txmiour. The early stages of tuberculous meningitis in
young women may resemble hysteria, but the eyes should be examined
for optic neuritis. Post-basic meningitis occurs in infants under one year,
and has a longer course. In marasmic conditions in children drowsiness
and convulsions may arouse the suspicion of tuberculous disease being
present, but in such cases the fontanelle is depressed because the intra-
cranial pressure is not raised.

Prognosis and Treatment, — Tuberculous meningitis is essentially a
chronic disorder, though its average duration varies considerably — ^m
three weeks to three months are about the limits. The prognosis depends
mainly on three things — first the period of the disease at which the patient
comes under treatment ; secondly, the height and range of the tempera-
ture, which is the measure of the activity of all tuberculous processes ;
and, thirdly, the extent of the tuberculous mischief in other organs. Until
recent years it was regarded as necessarily fatal, though cases of undoubted
recovery have been published (Trousseau, Rilliet, Carrington). Curiously
enough, the treatment which was most successful consisted of calomel and
pot. iod., remedies which are directed against syphilitic lesions, and it
seems possible that some of the alleged cases of recovery may have been
syphilitic meningitis. Lumbar puncture (§ 626), originally suggested by
Quincke simply to relieve the intracranial pressure, has in several instances
resulted in recovery (Henkel, Barth, and others). 10 or 20 c.c. may be
withdrawn and the operation may be repeated if necessary, ice-bags
applied to the head, bromides or chloral internally, or evaporating lotions
to the shaven scalp, relieve the headache. Mercurial and iodoform oint-
ment rubbed into the scalp is recommended in chronic cases.

§ 549. II. Acute Meningitis (Leptomeningitis ; AraohnitiB ; Acute Hydrooephftlos)
is a diffuse inflammation of the pia mater and arachnoid (leptomeningitis), simple
or purulent, according to its exciting cause, chiefly affecting the convexity of the
brain.

Symptoms, — ^There are symptoms and signs of cortical irritation (§ 647), followed
by signs of compression — i.e,, increased intracranial pressure. The inflammation
affects the convexity rather than the base of the brain, the reverse of tuberouloos
meningitis, and the symptoms consist, therefore, of muscular twitchings, spasms,
sometimes convulsions, and later on paralysis of the muscles of the body, rather
than paralysis of the cranial nerves as in tuberculous meningitis. There is no pro-
dromal stage, the invasion being sudden. The course of the disease lasts usually
a few days to one or two weeks. (1) The temperature runs a pyaamio oourse with
wide variations, and there may be rigors. Other symptoms are (2) severe persistent
headache ; (3) delirium ; (4) retraction of the head, rigidity of the muscles of the neck,
diffuse hypersBsthesia and pain, especially about the neck, from involvement of the
spinal nerve roots. Optic neuritis and ocular paresis are rare. (5) There may also

§649] AOUTE MENINGITIS in

be vomiting, flushing of the face and conjunotivsa, the ** t&che oMbrale " of Ticusaeau,
and herpes on the lips or face. Kemig^s sign (§ 514c) is present if the inflammation
extends to the spine. (6) There is usuaJiy a history or evidenoe of some cause, since
the disease is ruely primary, the most common cause being disease of the petrous
hone, with or without ear disease, attended by a purulent discharge.

Etiology, — ^The most frequent cause of purulent meningitis is (1) extension of in-
flammation from adjacent parts, either horn unthotU — e,g., in caries or necrosis of
the cranial bones, erysipelas of the face or scalp — or from wUhin — e,g., a cerebral
abscess or sinus thrombosis. Any of the bones may be involved, but disease of the
petrous bone is the most frequent cause, with or without otitis media ; nasal or ethmoid
disease is a much less common cause. In disease of the cranial bones a chronic localised
thickening of the meninges may prevent a localised collection of pus, a subcranial
abscess, £rom spreading laterally ; but the edges are liable at any time to become
softened, and so permit of a generalised purulent meningitis. (2) Punctured wounds
of the scalp may cause meningitis in the same way as in cerebral abscess formation
iq.v.). (3) Pyaemia and malignant endocarditis may be attended by a purulent, and
rapidly fatal form of the disease. (4) The pneumococcus is probably one of the
commonest causes of suppurative meningitis. A primary meningitis may be due to
pneumococci found in the oerebro-spinal fluid, without pneumonia being present.
(5) Secondary to other constitutional disorders such as the specific fevers, influenza,
diphtheria, acute rheumatism, measles, small-pox, erysipelas, scarlet fever, anthrax,
gonorrhoea, and actinomycosis, also, it is said, to gout, chronic nephritis, and heart
disease in the terminal stages. (6) A primary cerebro-spinal meningitis also occurs
in tho sporadic and epidemic form, due to the diplococcus intracellularis (§ 627).
(7) Tvherculoua and post-basic meningitis are special forms described respectively in
§ 548 and below.

Diagnosis, — Acute meningitis has to be diagnosed from other forms of meningitis
and from acute specific fevers, pneumonia, and other acute diseases, which may simulate
meningitis at their onset with headache, vomiting, and absence of local signs.
PTieumonia may be very deceptive at first before lung signs are definite, but the
rapidity of respiration affords us a clue. Tuberculous meningitis has a more insidious
onset, a prodromal stage and a prolonged course. When there is otitis media, menin-
gitis may require to be differentiated from cerebral abscess, which has more localised
symptoms, a low temperature after the first day or so, and the headache lasts longer
before the onset of coma. In septic sinus thrombosis the temperature is marked with
recurring rigors, and local signs of the sinus involved are usually seen, such as the
brawny swelling in the neck in lateral sinus thrombosis. The diagnosis of the cause
also requires investigation, especially in children. When due to otitis, the patient
usually holds the hand to the he€bd. Lumbar puncture (§ 626) and cultures may aid
us in the diagnosis of the cause.

Prognosis. — ^The disease usually runs a fatal course in a few days, but it may com-
pletely recover, or if traumatic in origin, it may pass into a chronic localised meningitis.
Recovery has been reported after the primary pneumococcus form, though this and
the other septic forms are generally fatal.

Treatment, — ^The patient must be kept in a dark room, perfectly quiet, the head
shaved, and an ice-bag applied. A purge should be given, preferably of calomel.
Some recommend blisters, or the cautery to the back of the neck. Only milk diet
is allowed. Mercury, especially in the form of inunction, is recommended, together
with large doses of iodide of potassium. The cause must be carefully investigated,
and where local causes are in operation, such as injury or disease of the scalp, these
must be treated surgically. In children and infants especially, puncture of the tym-
panum, with consequent outlet of a little pus, has often resulted in the prompt relief
of symptoms of intracranial irritation. Lumbar puncture (§ 626) not only affords
a clue to diagnosis of the primary malady, but may, by the relief of tension, result in
recovery.

III. Posterior Basic Infantile Meningitii may be acute, but is usually more chronic.
It is a disease occurring in infants under twelve months, due to inflammation in the
posterior fossa of the skuD, associated with a special diplococcus, the diplococcus
of Weiohselbaum. This is the same microbe as that of epidemic cerebro-spinal

774 THE NERVOUS SYSTEM [ §

meningitig (§ 373), and post- basic meningitis is now (1912) generally regMcied as *
sporadic, sub-acute form of that disease. The exudation ^ues together the oerv-
l]«llum and medulla, leading ultimately to the blocking of &e foramen of Maiendia
and distension of the ventricles (hydrocephalus). The characteristic Qympicmt
are (1) the gradual onset of the retraction of the head, which may amount to opistiio-
tonos of the spne with flexor and extensor spasm of the limbs ; (2) staring of the
eyes, with blindness, appears quite early in the disease, unassooiated with optic
neuritis, for it is due to involvement of the occipital cortex ; (3) vomiting ; (4) Hgidiftj
of the limbs, which may be general or localised to one extremity ; (5) parozyama ol
high fever lasting a day or two. The disease occurs in infants from tiiree to twelve
months old, only occasionally in older children. It is diagnosed from taberculow
meningitis by the age of the patient, the greater degree of cervical opisthotonos, the
longer course of the disease, the absence of optic neuritis in post-basio meningitis ;
and by lumbar puncture.

Prognosis, — ^The disease often runs a very prolonged course of weeks or mootha
Death has taken place after nineteen months. Cases may undoubtedly reooTor:
Drs. Lees and Barlow say one in six recover completely. In others grave aequefe
remain : hydrocephalus resulting from the distension of the ventricles ; UindoMi
(without optic neuritis) deafness (with consequent loss of speech) ; and defective
inteUigence ; or a combination of these.

Treaiment, — Merourial ointment should be rubbed into the neck, and iodide of
potassium in doses of 1 to 3 grains every two hours is believed to cause absorpiioii
of the exudation. Lumbar puncturo affords both a due to diagnosis (| 626) moA a
means of treatment,

IV. ^^emio Oerebro-Spinal Meningitis has already been described in § 373.

§ 650. V. Intracranial Abscen. — Abscess of the brain may occur in an acute o[
chronic form.

The S3rmptoms of oold or chronic abscess are identical with those of any other oecebfal
tumour, apart from the history and the symptoms roferable to the condition whiob
caused it. In quite a number of cases the history of a cause is wanting. »nd soeh
cases present only fche features of intracranial tumour (g.v.). The commonest cause
of cerobral abscess undoubtedly is suppurative middle-ear or bone disease.

The Symptoms of acute abscess of ^e brain may be divided into three stages. The
initial or inflammatory stage lasts from twelve hours to three days ; in some oases it
has lasted a week. Very often this stage may not be noticed ; and in most instances
the patient does not come under observation until it is over. The three ohiel
symptoms which characterise this stage aro pain, vomiting, and rigors, (i.) The pam
in the head may be burning, shooting, and continuous or intermittent, and there is
tondemess over the seat of the abscess, (ii.) The vomiting occurs without nausea.
and has no relation to food, (iii.) The rigors vary greatly in severity, from a abght
shivering to a shuddering. If the rigors aro frequent, there is probably present some
83rBtemic infection or sinus thrombosis {q,v,). The temperature in this stags is aboTe
normal, but not high. If the disease be due to otitis media, the discharge stops.
The second or collapse stage^ shows symptoms similar to the first stage, only mu<^ less
marked, (i.) The pain is diminished ; the patient may lie quietly moaning with the
hand over the affected part. Tenderness is brought out on peroussion. and is useful
in localising the site of the mischief, (ii.) Vomiting and vertigo occur on movement
only, (iii.) Cerebration is slow ; the patient will answer questions correctly, bai
only after long delay, and he may fall asleep in the middle of a sentence, (iv.) TV
temperature in this stage is normal or subnormal, if the abscess is unoomplioated.
(v.) The pulse is slow and full (30 to 60). Respiration is slowed, (vi.) Optic neuritat
develops ; and (vii.) paralyses may occur, which aid in diagnosing the site of the
lesion. This stage lasts from one to five weeks. In the lAtrcf or paralytic stage the absee«
terminates in one of three ways : (i.) By compression symptoms — deepening stupor,
coma, and death, (ii.) The abscess may open on the siurface of the brain, leading to
meningeal s3rmptoms with high temperature, quick pulse, vomiting, convulsions, etc

^ Some call this the latent stage, but Sir William Macewen objects to the use of such
a term in reference to a condition where symptoms are present.

§ 651 ] INTRACRANIAL ABSGB88 776

(iii.) The absoess may open into the ventriolee of the brain, an event oharaoteriaed by
lividity, dilatation of the pupils, stertorous breathing, high temperature, conyulsions,
ooma, and death within twelve hours.

Diagnoaia. — ^Abscess of the brain has to be diagnosed from acuU tneningiiia, in
whioh the symptoms are more of an irritative oharaoter, with high temperature and
quickened pulse. Lumbar puncture reveals a leucocytosis in the latter. In ainua
ihrombosia there are recurring rigors and local signs of the involvement of the sinus.
It must be remembered that both meningitis and thrombosis may accompany abscess,
and in this case the symptoms are confusing. If meningitis and abscess occur
together, the presence of the latter will be indicated by a slower pulse than would be
met with in uncomplicated meningitis. Intracranial tumours resemble abscess. The
slow progress of the symptoms, the greater amount of optic neuritis, and more definite
focal phenomena, with the absence of rigors, and of any source of abscess formation,
are in favour of a diagnosis of tumour ; while the presence of a subnormal temperature
is in favour of abscess. In cases of abscess leucocytosis is found in the blood.

Oauaea of cerebral abscess. — ^Many valuable observations have been made in this
domain. Briefly, the causes of cerebral abscess may be said to belong to three cate-
gories— disease or injury of the cranium or scalp ; pyaamic infection from the scalp
or other parts ; and softening of a tuberculous mass (very rare). The locality of the
abscess depends a good deal upon its source. The chief causes are : 1. Middle-ear
disease is by far the most ioommon cause. The abscess occurs in the temporo-
sphenoidal lobe, or less commonly in the cerebellum. There is usually necrosis or
tuberculous disease (caries), or occasionally syphilitic disease of the petrous bone, (i.y
The inflammatory process spreads through the meninges over the tegmen tympani
(roof of the tympanum), and if the local adhesions be present to prevent lateral ex-
tension, the process goes on, even without any erosion of the bone, to ulceration of
the brain, and consequent pus formation within the brain substance, (ii.) Or cerebral
abscess may form in the white matter, the grey matter of the cortex of the brain
remaining iminvolved. Here the inflammation spreads along the perivascular sheaths
of the vessels or along the veins entering the brain. Briefly, the foregoing means
that abscess may occur (a) by contiguity or (6) by extension along the lymphatic
sheath of the vessels, or along the veins from a distance. 2. Disease of the frontal
sinus, of the antrum of Highmore or nasal bones causes abscess in the frontal lobe.
3. Injury, such as compound fracture, with necrosis of the bone, may cause an abscess,
the position of which depends upon the seat of the injury. 4. Wounds of the scalp or
abscess, where the skin is healed, but there is pus formation beneath the bone. 5.
Garbunde of the face (rare) or scalp causes abscess when septic matter passes by the
facial vein and pterygoid plexus, or by the ophthalmic vein, to the cavernous sinus.
6. Disease of the orbit causes abscess by a simUar method of extension. 7. Erysipelas
(rare) more often causes leptomeningitis. 8. Abscess of pycsmic origin may occur in
any part, bub the most common situation is the occipital lobe. The py»mic sources
are septic embolism — e.g., in malignant endocarditis — and pyaemia.

Prognosis and Treatment. — Early diagnosis and correct localisation of this serious

condition are most important, for surgical treatment is successful, but untreated cases

usually die. In some cases the abscess undergoes apparent cure, and, if small, it

may remain encapsuled for years, or may even dry up. Macewen mentions a few

oases where the abscess discharged externally tlurough eroded bone. The usual

course of an acute uncomplicated abscess is from two to six weeks. A chronic abscess

may last months or years, but is always a source of danger. After remaining without

symptoms for years, it may suddenly burst into the meninges or into the ventricles.

Uncomplicated abscess, if discovered in good time, is readily amenable to treatment

in the hands of a skilled surgeon, but if symptoms of meningitis or sinus thrombosis

accompany it, the prospect is much more grave, especially if the meningitis is diffuse.

§ 551. VI. Sinui Thrombosis, thrombosis of the cerebral sinuses, may be Pyoobnio,

and accompanied by pyrexia and stupor, or NON-PTOOEino, accompanied by stupor only.

a. In Pyogenic Sinui Thiomboiis there is pyrexia of a pysBmio type — i.e„ wide

variations with rigors. Any one of the sinuses may be involved, but the lateral sinus

(secondary to suppurative middle-ear or temporal bone disease) is thr favourite

position.

776 THE NERVOUS SYSTEM [S

The SymptofM oommon in septic thromboBis of any of the sinnaes are (L) aewete
headaohe, Tomiting, and high fever of a pyogenic type, accompanied by rigoiB
sweats (see chart, § 383) ; (ii.) optic neuritis supervening in a day or two, and
photophobia ; (iii.) drowBiness deepening into coma, and if prompt operative
be not adopted, death ensues.

The Localiaing Signs of the particular sinus thrombosed depend on the extenaioo
of the inflammation along the corresponding extracranial veins, and on the preeeoce
of the cause. Thus, in lateral sinus thrombosis there are pain and tendemefls in tiie
mastoid region, together with the other signs of a suppurative otitis media or Hlpnnip
of the petrous bone ; the inflammation spreads down the course of the jugular vein
on the same side and backwards behind the mastoid ; and oonsequentlj there is
generally some hard brawny swelling in these positions ; if there has previoualy been
a discharge from the ear, it mostly ceases. When the longitudinal sinus is thrombooed,
the localising signs consist of oodema of the scalp, distension of the veins ovier the
forehead, and sometimes strabismus, associated with convulsions at the onaet. This
is the sinus which is most often affected by non-pyogenic thrombosis, and when
pyogenic in origin, the cause is usually some septic lesion of the face or scalp. When
the cavernous sinus is affected, the localising signs are OBdema of the eyelids and root
of the nose, sometimes also of the pharynx, exophthalmos, and paralysis of the second,
third, fourth, ophthalmic division of the fifth, and sixth nerves. Pyogenic Uuronaboais
of this sinus may arise from some septic lesion of the orb^t, nose, pharynx, or fooe.

The Diagnosis of pyogenic sinus thrombosis from septicemia is very difficult, antesB
the local signs are pronounced. Acvie meningitis is also differentiated with diffioulty.
but here we get a lower temperature without rigors and sweats, and retraction of
the head and neck. In cerdnxd abscess the temperature is normal or subnormal after
the initial rise, and it is accompanied not so much by stupor as by headache and
paralysis of the cranial nerves.

The Prognosis of pyogenic sinus thrombosis is exceedingly grave, unless it is prompUy
dealt with by surgical measures, such as trephining over the mastoid cells, tying the
jugular vein below, cutting down upon the lateral sinus, and turning out the clot.
With these measures cases may recover, not without.

6. Non«Pyog6nio Sinui Thrombotis gives rise to coma ({ 530) mainly in marasinie
conditions. It is met with among in&nts suffering from prolonged diarrhoea, among
the aged, and less frequently in adults in the last stages of exhausting diseases, sooh
as phthisis or cancer and in chlorosis. The superior longitudinal is the sinus most
often affected. Headache, passing on to drowsiness and coma, are the Ift^/Ung
symptoms ; the temperature may be slightly raised, but it never forms a prominent
feature. In adults delirium may mark the onset, but the condition is difficult to
diagnose with certainty. In infants the coma supervenes almost imperceptiblj upon
the drowsiness which accompanies their exhausted condition. In childr^ epistazis
and convulsions should make one suspect the condition, even in the absence of
localising signs. The localising signs are mentioned under Septic Sinus Thrombosis.

The Prognosis is grave, especially in adults. Children may recover, but only wi^
impairment of intellect.

TreaJtmenl, — ^The patient should be kept at rest, with the head and shoulders slightly
raised. The neck must not be bent, lest the blood be hindered in its return. Tonics
and stimulants may be given.

Vn. Pyrexia, usually of short duration, may accompany certain inftrsoraiiisl Isnoas
of acute onsst, such as (i.) heemorrhage, especially into the pons, when there is sudden
coma, contracted pupils, and hyperpyrexia (see Apoplexy, § 531) ; (ii.) lesions occurring
in the course of chronic degenerative disease of the central nervous system, such as
disseminated sclerosis and G. P. I.

GROUP IV. MOTOR DISORDERS OF THE NERVOUS SYSTEM,

Motor disorders of the nervous system may consist of Paralysis {bdow),
Inco-ordination (§ 577), Increased Muscular Action (§ 582), or
Muscular Atrophy (§ 600).

562 ] HEMIPLEGIA 777

a. Paralysis.

Paralysis may take the form of —

Hemiplegia { 552

Paraplegia § 556

Braohiplegia § 567

Monoplegia and single nerve paralysis § 568

Greneralised paralysis § 573

The jxUierU comflains of weakness or paralsrsis of the linibs on one side
OP THE BODY. The case is one of Hemiplegia, which may be either of
sudden onset or of gradual onset.

§ 552. Hemiiilegia, paralysis of one side of the body, is due to a lesion
of the internal capsule or some other part of the motor tract of one hemi-
sphere, somewhere above the decussation in the medulla.

The Clinioal Investigation of a case of hemiplegia comprises an examination of
the paralysed limbs, the oranial nerves, the cardio-vasoiilar system, the urine, and
the viscera, and a study of the history and mode of onset. Our chief object is to
ascertain the position and nature of the lesion.

Symptoms. — In nine cases of hemiplegia out of ten the loss of power

in the limbs is on the same side as that in the face ; when it is on opposite

sides it is known as *' crossed hemiplegia," and the lesion is situated in

the pons. The arm is usually more afiected than the leg, and the leg

than the face. Only the lower part of the face is affected, the food collects

round the teeth on that side, but the patient can close both eyes. If the

tongue is paralysed, during protrusion it is turned to the afiected side,

due to the unbalanced action of the healthy genio-hyoid and genio-hyo-

glossus. Hemiansesthesia on the paralysed side is not present unless

the hinder limb of the internal capsule is also involved. There may be

an initial or early rigidity, coming on at the outset and lasting a few hours

(as in cases of heemorrhage), or coming in a few days' time and lasting for

a few weeks (as in cases of irritative lesion). There is also a late rigidity,

which comes on in all cases of hemiplegia after a few weeks or months,

and lasts permanently, and is due to descending lateral sclerosis.^ In

the course of years the muscles may undergo a certain amount of orgathic

cofUracture, due to intrinsic changes in the muscular substance, and the

hemiplegic muscles are also liable to various kinds of tremor, mobile

spasm and athetosis. These are especially common after the hemiplegia

of childhood. The other features are those of an upper neuron paralysis

— ^viz., (1) iAiQ deep reflexes are increased ; (2) there are no electrical

changes; and (3) there is no wasting beyond that of disuse. Finally,

there are vaso-motor cUterations in hemiplegia. There are known to be

centres in the cortex, irritability of which produces coldness and paleness

of the limbs. If the lesion producing the hemiplegia causes irritation

of these centres, the hemiplegic limbs are paler, colder, or bluer. If, on

the other hand, it gives rise to suppression of function, then the paralysed

^ Rare cases have been recorded in which the paralysis remained flaccid (h^miplegie
flasque of Bouchard).

778 THE NERVOUS SYSTEM £ f

limbs are congested, sweating, and sometimes oedematous. These con-
siderations explain the apparently contradictory observations made as to
general dropsy, which sometimes avoids and is sometimes present in
excess in the paralysed limbs, and the observation that the pnlse is some-
times smaller, sometimes larger in the paralysed arm, and, finaUy, of die
fact that the pupil is generally contracted on the paralysed side, either
from paralysis of the sympathetic or from irritation of the third cranisl
nerve. In all organic diseases of the brain which produce hemiplegia
there is generally more or less mental disturbance, and this is particularly
marked in cortical lesions, such as tumours of the cortex, hsemorrhages
on the cortex, and various meningeal affections, particularly when tiie
front of the brain is involved. Aphasia (§ 534) is associated witli ri^t
hemiplegia in many cases owing to the involvement of Broca's con-
volution ; in left-handed persons left hemiplegia may be so associated.

The chief Causes of hem%j)legia (ten in number) may be conveniently
divided into those of sudden onset — i.e., in the course of a few minutes or
a few hours — and those of more gradual onset — i.e., in the course of days,
weeks, or months.

A sudden onset always indicates a vascular lesion —

Injury.

HsBmorrhage.

Embolism.

Thrombosis.

In hysterical hemiplegia also the onset is generally sudden.

A gradual onset may be due to—

Intracranial tumour.

Abscess.

Chronic cerebral meningitis and pachymeningitis.

Altered blood states (chorea, diphtheria, anfemia, pregnancy, eto.).

Chronic degenerations of the nervous system.

The age of the patient is an important aid in the diagnosis of the nature
of the lesion in hemiplegia.

In the first half of life suspect in order : Embolism ; thrombosis
from syphilitic endarteritis ; hysteria (in females) ; tumour ; abscess ;
haemorrhage in childhood (occasionally) ; post-febrile and other blood
conditions.

In the second half of life in order of frequency we get : H»morrhage ;

thrombosis from arterial degeneration ; tumour ; aneurysm ; chronic

degenerations of the nervous system.

Syphilis plays a very important part in the causation of hemiplegia, which may
be produced in several ways : (1) A syphilitic endarteritis and tlux>mboBi8 ; (2) llie
formation of a gummatous tumour ; (3) meningeal affections ; or (4) aneurysm.

(a) The Sudden Causes (vascular lesions) are much more frequent than
those of gradual onset.

(1) Injury to the Head may produce hemiplegia by depressed bone,
extravasated blood, or, later on, by the formation of an abscess or a cica-
trix. It is known by (i.) the history of injury ; (ii.) by being preceded

i 658 ] HEMIPLEGIA 77 9

or accompanied by loss of consciousness, stupor, or convulsions ; and
(iii.) early rigidity in the affected limbs.

(2) HEMORRHAGE (apoplcxy, § 531) from rupture of a vessel or an
aneurysmal dilatation occurs most frequently in the lenticulo-striate
artery (Fig. 154, p. 780) in the internal capsule, though it may occur
anywhere. Its differential characters are as follows : (i.) The onset is
usually very sudden, with coma, and often convulsions, the degree of these
symptoms depending on the locality and the extent of the haemorrhage ;
occasionally, when the haemorrhage is small, headache, giddiness, or
vomiting alone mark the advent, (ii.) The patient is usually of middle
or advanced life, and often presents a history of chronic interstitial
nephritis, though cerebral haemorrhage is also known to occur in children,
(iii.) The rigidity of the affected limbs comes on with the hemiplegia, and
is succeeded by late rigidity and sometimes by tremors. Meningeal
haemorrhage rarely occurs unless the meninges are previously unhealthy,
as in general paralysis.

(3) Embolism (§ 531), blocking of a cerebral artery, often of the middle
cerebral artery, may arise from a fragment of a vegetation from a cardiac
valve, or by some septic or other embolus. It causes a localised cerebral
ischaemia and softening. It is differentiated by (i.) sudden hemiplegia,
accompanied and often preceded by severe headache and giddiness ; but
(ii.) rarely by convulsions, and as a rule consciousness is not lost ; (iii.)
the patient is often young ; (iv.) there is often a history of rheumatic
fever, and cardiac valvular disease, especially mitral stenosis ; (v.) the
muscles are generally flaccid at first, and the hemiplegia is more often
on the right side, because of the continuity of the left middle cerebral
artery with the aorta.

(4) Arterial Thrombosis (§ 531) consists of coagulation of the blood
within an artery owing to its occlusion by disease of the wall, or a throm-
botic condition of the blood, as in phthisis. Senile change in the wall
of the artery, associated with cardiac enfeeblement, is its commonest
cause. In young subjects syphilitic endarteritis is very often in opera-
tion. Venous thrombosis is not necessarily associated with hemiplegia ;
it is referred to under Coma. Thrombosis of an intracranial artery is
recognised by (i.) moderately sudden advent of hemiplegia, but without
unconsciousness or convulsions ; (ii.) the paralysed muscles are flaccid
at first, and there is no early rigidity ; (iii.) the patient is mostly advanced
in years, imless the arterial disease be syphilitic.

Arierud Occlusion is the commonest of the cerebral syphilitio lbsions, and in
that way becomes the commonest cause of hemiplegia under forty. A syphilitio
endarleritis gradually occludes an artery, and results in thrombosis and " softening '*
of a circumscribed area, just as does atheroma of the cerebral vessels. The symptoms
of a syphilitic softening resemble atheromatous thrombosis except in two particulars
— ^namely, (1) the extent of the softening, and therefore of the paralysis is often more
limited {e,g,, one arm or one leg) ; and (2) the patient is generally young or middle-
aged. A thrombotic hemiplegia in a person under forty or forty>five is almost
certainly syphilitic. This kind of cerebral syphilis is distinguished from the meningeal
lesions or gumma by the absence of irritative signs. The advent, contrary to what

THE NEBV0V8 SYSTEM

Lmlinb-
hroocibv

Fig. Hi.— Tat Base of tHX BbiIk, Bhowing the uterisL distrtbutioD ud the cnniikl necTM.— b
tho obUquo iectlon of the left hemlaphere Are Been fiom without Inwaidi — groy matter of tbt
island ot Keil ; clauatrum (grey) ; exlernal cspinle (whttal ; leaUcnlBr □dcIsus [greji : InUnuI
upsnlo (white) with artery ot hemorrhaEe : and caadate naclsni (grey). I., Ollactory lo*"'
II., optio chtamB; lU., bUurcaUoD of veitfibral artery between tho Ihird niirvei ; IV. ((■
right cms cerebri), beside fourth nerve ; V. (oa jioai TaroUl). beside filth nerva : VL, (litk
necve (ahduceos) ; VII., facial Derve ; VIII., aadttory nerve ; IX., glouo-phairngMl nanti
S-, vagal or pneumogaatrle : XL, spinal aoceuory ; XII., bypogloual nerre.

§668] HEMIPLEOIA^INTRAGBANIAL TUMOUB 781

one would expect from the gradual occlusion of an artery, is always more or less
sudden, unaccompanied by unconsciousness, convulsions, delirium, rigidity of limbs*
optic neuritis, or paralysis of cranial nerves.

(5) Hysterical Hemiplegia is recognised by the following characters : (i.) The
advent is usually sudden, and often dates from an emotional shock or hysterical
seizure ; (ii.) the paralysis is usually flaccid, incomplete in degree, and the face is
exempt ; (iii.) it is often accompanied by hemiansesthesia of the same side, sensitive
and sensorial ; (iv.) the condition varies from day to day, and may disappear suddenly,
unexpectedly, and completely ; (v.) the youth and sex of the patient are characteristic,
and she presents other evidences of the hysterical diathesis (q.v.), and a previous
history of nervous attacks.

(h) Hemiplegia of Gtradiial Onset, in the course of weeks or perhaps
months, points to one of the following conditions : Intracranial tumour,
abscess, chronic cerebral meningitis (and pachymeningitis), altered blood
states, or chronic degenerations of the nervous system. Nevertheless,
tumour, aneurysm, and abscess may sometimes run a latent or prolonged
course, and then suddenly develop hemiplegia.

§558. (6) Intracranial Tumour, the sixth cause of hemiplegia, may
exist for a long time without any symptoms, especially if the tumour be
situated in the frontal region, but it is generally characterised sooner or
later by a progressive and insidious hemiplegia. As regards the nature
of the tumour, syphilitic gumma is one of the most frequent in adult life,
and is especially apt to affect the meninges at the base or over the con-
volutions. It is well to bear in mind that malignant tumours may occur
in the brain ; sarcoma may occur primarily quite early in life, and a
secondary growth of cancer may develop in advancing years. A tuber-
culous nodule is only met with in the young, and a history or the existence
of tubercle elsewhere point to the tumour being of this nature. An
aneurysmal tumour is not common. Tumours may also arise from the
dura.

The Symptoms of intracranial tumour vary very considerably with its
locality (which will be discussed in § 554), but most cases present the
following symptoms in common : (i.) Headache, vertigo, and vomiting
from time to time without nausea, precede and accompany the illness,
especially if the tumour be situated near the cortex, (ii.) Jacksonian
epilepsy (§ 598) is also frequent if the tumour be situated in or near the
cortex, (iii.) (Edema of the optic discs, leading to atrophy, is present in
a considerable proportion of the cases (five-sixths. Sir William Gowers^).
For the occurrence of these the tumour need not be near the optic nerve ;
it is believed to be due to increased intracranial pressure. The two
symptoms — ^headache and a marked degree of optic neuritis — ^are alone
very strongly suggestive of tumour of the brain, (iv.) Paralysis of other
cranial nerves, depending on the position, but especially of the sixth,
fourth, and third, owing to their relatively long course within the cranium,
(v.) Incomplete hemiplegia, coming on slowly and insidiously, but pro-
gressively, with ridigity and the other features of the upper neuron

^ *' The Diagnosis of the Nature of Organic Brain Disease/' Phonographic Medical
Library, vol. i., 1897.

782 THE NERVOUS SYSTEM [5

paralysis, acoompanied by other symptoms according to the uitnation
of the tumour (§ 554). Mental apathy and delayed cerebration are usuaDy
present.

(7) Absobss of the Brain, the seventh cause of hemiplegia, is rarely priiii»zy. It
may arise from (1) direct extension, as from disease of the cranial bones, syphilitic.
tuberculous, or after injury, or following diseases of the mastoid, ethmoidal, frontal
or nasal sinuses. (2) Abscess also arises from septic blood conditions — ^pysmia,
emboli from malignant endocarditis, or from the lungs when affected with taberdp.
bronchiectasis, gangrene, or abscess. It has followed influenza and the specific fevers.
The symptoms of cerebral abscess resemble those of tumour, and differ according
to the site. Abscess of the temporal lobe after middle-ear disease is not on-
common, and in this case the hemiplegia is of slow onset, is ill-defined, and the face
is notably involved. The other symptoms are described in Intracranial Inflammik-
tion, § 650. Pyrezial symptoms are only found at the onset and the termination of the
case.

(8) Chronic Mbninoitis and Pachtmbnikgitis (fibrous thickening of the meninsEts)
sometimes occur (though rarely) as solitary lesions. The condition is mostly doe
either to chronic alcoholism, syphilis, or injury, and some say that in the absence of
these, chronic meningitis may be excluded. Tuberculous meningitis may also cause
hemiplegia, especially in children, (i.) The advent is usually gradual ; (ii.) the degree
of the hemiplegia is dight ; (iii.) optic neuritis is frequently present ; (iv.) veiy generally
some of the cranial nerves are involved as they pass through the membranes leeions
of the sensory nerves causing pain, disease of the motor nerves causing atrophie
paralysis with R. D. (v.) There are always some signs of mental alteration, and not
infrequently epileptiform convulsions from irritation of the cortex. Indeed, epilepsy
occurring for the first time in a person of thirty or forty is very probably due to
syphilitic disease of the meninges.

Syphilitic Meningeal Affections may also take the form of a gummatous deposit,
either primarily or secondarily to osseous lesions. These are distinguished clinioaUy
by severe and continuous headache, and the presence of irritative signs.

(9) Altebbd Blood States, such as those due to chorea, severe anaemia, pregnancy,
typhoid fever, influenza, scarlet and other fevers, may give rise to hemiplegia. The
lesion is possibly a thrombosis or some more transient vascular change. It is recog-
nised by (i.) the antecedent history, and (ii.) the incompleteness and transitory natnre
of the paralysis.

(10) Hemiplegia may also form a minor feature in the course of several Chbokic
Deobnerattve Conditions of the nervous system, such as disseminated sclerosis.
general paralysis of the insane, and bulbar paralysis, the diagnosis of which is dealt
with elsewhere.

Prognosis of Hemiplegia. — If the paralysis has been considerable, one
can hardly hope for complete recovery. The most favourable kinds, both
for recovery and for life, are those due to injury, hysteria, and an altered
blood state. Next in order comes syphilis, which, if diagnosed early and
treated thoroughly, may generally be cured. All the other causes are
more serious. Localised cerebral tumours are sometimes removable, and
life may be prolonged, but the paralysis rarely disappears entirdy.
Abscess is capable of surgical treatment. The most unfavourable kinds
of hemiplegia are those due to embolism, thrombosis, and haemorrhage,
the last named being the gravest of all ; and the usual history in these
cases, even if the patient recover from the apoplexy, is that a recurrence
takes place during the ensuing year or two, in which the patient dies.
As regards symptoms, it is usual for the leg to recover before the arm ;
if the converse of this happens, the prognosis is certainly less &vourable.

§ 554 J LOCALISATION OF INTRACRANIAL TUMOUR 783

as showing that the damage is too great for the substitution of funotion
which leads to the recovery of the leg. The formation of blisters or
sloughs over the gluteus is of bad prognostic significance. The general
condition of the patient, and the existence of some other disease,
such as chronic granular kidney, may also constitute unfavourable
circumstances.

Treatment of Hemiplegia, — ^In haemorrhage the patient should at first
be kept at perfect rest ; the treatment of hsemorrhage, embolism, and
thrombosis should be directed to the cardio-vascular system (see § 531).
Intracranial tumour and abscess, unless we can positively exclude syphilis,
should first be put on full doses of iodide and mercury while the locality
is being accurately diagnosed, with a view to surgical interference should
these remedies fail. Headache and the other symptoms of tumour may
be relieved by lumbar puncture (p. 897, § 626). For aneurysm full
doses of iodide of potassium are useful. Chronic meningitis, if of a
syphilitic nature, should be treated accordingly ; if due to injury, and
the position of the focus of the disease can be diagnosed, surgery may
be invoked. As regards the treatment of the paralysed limbs, a great
deal can be done by the judicious application of massage, galvanism, and
galvano-faradism. The first improves the nutrition of the muscles con-
siderably, the second and third maintain and improve their functional
activity. Galvanism only may be applied to rigid muscles, and general
hygienic measures will aid. Electricity should not be started till two
months after a cerebral heemorrhage, and should be stopped if headache,
faintness, or fatigue appear. If the motor tract is definitely destroyed,
nothing will restore its fimctions completely, but a good deal may be done
by the means just mentioned, and by the education of other centres to
take on the functions of those destroyed. Strychnine must be avoided
when the muscles are rigid. The paralysed muscles should be prevented
from contracting by means of splints.

§ 554. The Looalisatioii of Intraeranial Lenoni may be conBidered first in regard to
certain recognised types of paralysis ; secondly, certain groups of 83rmptomB corre-
sponding to the three basal fossA ; and, thirdly, the symptoms pointing to positions
in the encephalon.

A. Lesions in certain positions give rise to certain types of pabalysis.

(1) Hemiplegia is usually due to a lesion in the internal capsule.

(2) " Crossed hemiplegia " (face on same side as lesion, body on opposite side) is
typical of a lesion in the lower part of the pons.

(3) Paralysis of the facial and sixth nerves on same side, hemiplegia of opposite
side, signifies lesion in pons at level of exit of facial nerve (Millard-Qubler
83nidrome).

(4) Incomplete paralysis of the third nerve on same side, with hemiplegia or hemi-
ataxy and facial paralysis on the opposite side, is typical of a lesion in the cms cerebri
(Weber's syndrome).

(5) Oculo-motor paralysis of the same side as the lesion, with tremor of the leg and
arm on opposite side, indicates a superficial lesion of one eras extending into the
teg^mentum and the neighbourhood of the red nucleus (Benedikt's syndrome).

(6) Conjugate deviation of the eyes indicates a lesion at or, more generally, above
the ocular nuclei. With destructive lesion of the cortex the eyes look towards the
same side as the lesion, but they look away from irritative lesions.

784 THE NERVOUS SYSTEM [\m

B. Intracranial tumonrs in the —

Ck)RTBX of the brain (see Figs. 145 and 146, § 501) usually produce convnLaoni-
Rolandic area, Jaoksonian convulsions starting in part controlled by afbct^ am.;
tender spot on skull over Rolandic area. Paralysis of opposite side flaccid at ki ;
monoplegia, rarely complete hemiplegia ; impaired muscle sense ; ataxy in fi&f
movements (e,g,, fastening buttons). If left inferior frontal involved, aphasia (Botoc
speech). The convulsions are preceded by aura of flashes of b'ght, if the lesioD •
in the occipital cortex ; by noises or music, if superior tempore -sphenoidal cortfi.
by odour, if tip of ^mporo-sphenoidal cortex.

Posterior Fossa — resemble symptoms of cerebellar (below), pontine, and medd-
lary tumours, but without conjugate deviation. Cranial nerves from VI. to ID
may be involved (Fig. 154, p. 780).

Middle Fossa — ^lesion of one third nerve, and symptoms of involvement of ere
cerebri (hemiparesis).

Anterior Fossa — ^paralysis of nerves entering the orbit, loss of sight and smell os
side of lesion. Sometimes no symptoms except mental dulness.

0. Destructive lesions in different positions in the encephalon are indicated u
follows —

Frontal Lobe — ^mental torpor and depression, sometimes exophthalmos on tk
side of a tumour, and perversion of smell. Usually no motor or sensory distorbaiKt.

OcoiPiTAL Lobe — altered field of vision (hemianopia) ; if bilateral, bUndnen ; '*
involving left angular gyrus, word-blindness.

Temforo-Sphbnoidal Lobe — deafness ; if in left superior convolution, won^-
deafness ; if tip, taste and smell affected.

Corpus Callosum — (i.) Gradual onset of hemiplegia, with vague hemiplcfc
s3rmptom8 on other side ; (ii.) mental torpor ; (iii.) coma and death without mvolt^^
ment of cranial nerves ; (iv.) headache and vomiting rare throughout.

Internal Capsule — ^hemiplegia, face and body, of opposite side. When posteria
part involved, hemianesthesia, hemianopia, disturbed hearing, tremor (especialy
when optic thalamus also involved), hemichorea, and athetosis. In a linear (aatefo-
posterior) lesion, paralysis of face and leg, arm escaping.

Optic Thalamus — ^hemianopia, hemianffisthesia, post-hemiplegio chorea. Ouuiot
with certainty be distinguished from lesions involving the sensory part of intentfl
capsule and optic radiations. Paralysis of emotional movements of faoe together wi<h
post-hemiplegic choreic disorders are in favour of a lesion involving opposite thalao»:«.

Corpora Quadrioemina — superior corpora : nystagmus, loss of papiUaiy eon-
traction to light and accommodation, ataxy if fibres to medial lemniscus invdved
Inferior corpora : auditory disturbance, partial deafness of both and especially (t
opposite ear. Defective mastication from involvement of motor root of V., and tlie
fourth nerve is sometimes involved. Lesions of corpora quadrigemina simalAte
locomotor ataxy or cerebellar tumour. Ophthalmoplegia and reeling gait, espeeiallj
if associated with bilaterally defective hearing, render diagnosis probable.

Crus Cerebri — simultaneous onset of III. nerve paralysis on side of lesion, um^
of hemiplegia (with marked facial involvement) on opposite side, is very characteristic:
and if tegmen involved, hemiataxy of opposite side.

Pons — very varied s3rmptom8 ; most characteristic are combination of paralyss of
v., VI., and VII. on side of lesion, and of body on opposite side. Upper part ofpo^f
Paralysis and anesthesia of faoe and body on side opposite to lesion. Lower f^
of lesion : " crossed paralysis," faoe on side of lesion, body on opposite side ; VL and
VII. paralysed together ; conjugate deviation to side away from destructive leooD ;
in acute lesions, contracted pupils and hyperpyrexia.

Medulla— difficulty in articulation and swallowing, associated with dlstorbanoefl oi
heart and respiration and paresis or paralysis of limbs on one or both sides. All eraniAl
nerves from VIII. to XII. affected. Often secondary to cerebellar or pontine disease*

Cerebellum — ataxy (reeling), static and dynamic, not affected by closing eyee :
movements fairly co-ordinated when in bed. Vertigo. Nystagmus. Panos of
trnhk or limbs. K.- J.*s sometimes absent. Hydrocephalus by pressore on veins of
Qalen leading to distended ventricles.T Compare § 581.

Pituitary Body — Bilateral hemianopsia ; sometimes acromegaly.

§§ 655, 666 ] PAjRA PLEOIA 785

§ 666. Hemiplegia in OMdzen difiers from that in adults in several respects. It
is met with in congenital and in acquired forms, the latter being usually under ten
years old. The child has a sudden fit of convulsions, followed by coma and hemi-
plegia. In after life, athetosis and post-hemiplegio chorea are common sequels, and
Jaclcsonian epilepsy is also seen. The affected limbs do not grow so well as the
others, though the musdes are not really wasted, and some may be hypertrophied
from the constant movement in athetosis. The mental condition in such patients
varies — it may be normal or merely dull; others, especially the congenital oases, are
idiots, with squint.

The Prognwis as to recovery is bad, but the duration of life is not affected by this
disease except in the congenital and mental cases, who frequently die in early life
from intercurrent diseases.

Etiology, — Congenital hemiplegia occurs from (i.) injury at birth, or protracted labour
causing meningeal hasmorrhage, or crushing the hemispheres together (Little's
paralysis) ; (ii.) porenoephalus (cavities in the brain) ; and (iii.) atrophy of one hemi-
sphere. Acquired hemiplegia comes on in the majority of cases before the second
year, rarely after the tenth year. The hemiplegia in such cases is apt to come on during
or after an acute specific fever, and has been found after death to be due to embolism,
thrombosis, or hsemorrhage. Tuberculous meningitis and tumour, cerebral abscess,
polio-encephalitis superior and trauma are also causes of hemiplegia in children.

Treatment. — The possibility that infantile convulsions are associated with a cerebral
lesion should be remembered, and bromides and a purge should be given. The
hemiplegia may profitably be treated by electricity and massage. The rigidity and
contractures are treated by massage and exorcises. And see Treatment, p. 796.

The fotient complains of weakness or paralysis of both legs. The
disease (general debility being excluded) is Paraplegia.

§556. Paraplegia is most often due to some structural or functional
disease of the spinal cord, for it is here that the motor tracts of the two
sides of the Body run side by side, and can therefore be affected by a
single transverse lesion. Paraplegia may also be due to disease of the
peripheral nerves.

It will be found convenient for clinical purposes to make three groups
of paraplegias :

(a) In upper neuron, spastic or rigid paraplegias, the paralysis is per-
sistent and progressive, the muscles are rigid, with no tendency to atrophy,
beyond that due to disuse, the deep reflexes are increased, and there are no
electrical changes . . . . . . . . . . • • § 557

(6) Paraplegias of the lower neuron typo are flacdd. In this type the
paralysis is persistent and continuous from day to day, the muscles are
atrophied, the deep reflexes are absent or diminished, and there is the
reaction of degeneration . . . . . . . . • • § 561

(c) In the functional or variable paraplegias the paralysis is less pro-
nounced and less persistent than in the foregoing ; it is apt to vary from
day to day, and there are neither atrophy nor electrical changes . . § 564

Clikioal Investigation. — Assuming that th^ case is really one of paraplegia, and
not simply a stiffness of the joints due to gout, rheumatism, or old age, it is desirable
(1) to investigate the history of the case, (2) to examine the spinal column, and (3)
to ascertain whether the x>aralysis conforms to the upper neuron type, the Iowqt
neuron type, or the functional or variable type.

(1) The history of the case throws considerable light on the nature of the lesion,
and particularly in regard to the mode of onset and evolution, the history of x>ain,
and the ago of the patient. The onset is very rapid in vascular lesions or those of an

*86 THE NERVOUS SYSTEM [fSf7

acute' inflammatory type. The onset takes place more gradually in some forms of
compression paraplegia, such as Pott's disease (§ 557), in multiple neuiitifl, cfaronic
myelitis, and syringomyelia. The history of pain in the spine or logs is of importaiw
and some observers even go so far as to divide paraplegias into painful and painkm
The presence of pain indicates an involvement of the nerve trunks or the poitenor
nerve roots, as in meningeal affections and tumours. Paraplegia in chUdhooi in a
large proportion of oases is due to Pott's disease or infantile palsy. A duUs from tveDtr
to forty are chiefly affected by paraplegia due to multiple neuritis, hysterical or
syphilitic paraplegia. In advanced life the slow degenerative lesions are more ofta
met with.

(2) Local examination of the spine should never be omitted. It will show us at «
glance whether or not angular curvature or malformation be present. Pbrcoaaoe
down the spine may elicit tenderness, as in Pott's disease, tumour, or meoiogMl
affections. Vertical pressure upon the head while the patient is sitting or staoding
will cause severe pain if vertebral caries or cancer be present, but not in hysterieal or
neurasthenic conditions. Rigidity or restricted movement accompanies all painfai
organic affections of the spine, as in meningeal diseases.

(a) The upper neuron, spastiOy or rigid paraplegias form the largest of
the three groups, and it contains a most important sub-group — viz,, iht
compression paraplegias. The three features of this kind of paraplegia
are those which belong to all paralysis due to lesions of the upper neonm
— viz., rigidity, increased deep reflexes, and no marked muscular wasting.
The members of this group differ from the functional paraplegias in their
steady and usually progressive course. The following are the causes of
the spastic paraplegias, placed more or less in order of frequency :

Oompresaion Paraplegias,

I. Compression paraplegia due to Pott's disease. *

II. Compression paraplegia due to tumours.

III. Injury.

Inflammation of the Cord or its Membranes.

IV. Myelitis and its varieties.

V. Hemorrhage (spinal and meningeal).
VL Embolism.
VII. Chronic spinal pachymeningitis.

Chronic System Lesions {Sclerosis),

VIII. Disseminated sclerosis, general paralysis of the insane, and tabes dontH^
— ocoasionaUy.
iX. Primary lateral sclerosis.

X. Ataxic paraplegia and Friedreich's disease (occasionally).
XI. Amyotrophic lateral sclerosis.
XII. Infantile cerebral and spinal paraplegia and other double cerebral or oen-

bellar lesions.
XIII. Toxic sclerosis.

Malformations.

§ 657* Compression Paraplegia is perhaps the conunonest form of qMitie
paraplegia* and is due to compression of the spinal cord, either by spinal
caries (Pott's disease), or other disease or injury of the vertebra, or a
tumour pressing upon the spinal cord.

The Symptoms common to all forms of compression paraplegia, io
addition to those just named belonging to upper neuron parapiegiM, &re

§M7] COMPRESSION PARAPLEGIA 787

(1) pain at some time from pressure upon the nerve roots, and, generally
speaking, it may be said that when the pain precedes the paraplegia the
lesion is extradural, when it is vice versa the lesion is probably intradural.

(2) The symptoms are apt to be more marked in one leg than in the other
(with the notable exception of Pott's disease).

I. Vertebral Caries (Pott's Disease, Tuberciilosis of the Spine) may be
regarded as the type of compression paraplegias. It used to be the
commonest cause of paraplegia in young persons. It is the commonest
of the compression paraplegias, injury coming next, and vertebral cancer
next. The parapl^a in Pott's disease is due to the pressure of the in-
flammatory products which accumulate outside the dura mater and
compress the cord. Its differential features are : (1) In the incipient stage
the patient, who is usually a child, probably complains of "stomach-
ache " or pains in the region of the umbilicus, the back, or the loins, due
to pressure on the nerve roots. A sense of constriction round the trunk
may be complained of. (2) The onset of the paralysis is usually gradual,
and is rarely quite complete, but on rare occasions the onset is rapid.
Both legs are afiected equally. (3) There are marked rigidity and increase
of the deep reflexes, often twitchings of the muscles. (4) In the early
phases jarring by percussion on the head or jumping on the heels causes
pain ; there is generally pain and tenderness of the spine, and in course
of time other indications appear at the seat of the mischief. (5) The
subjects of the disease are mostly children or young persons who have
a family or antecedent history of tuberculosis, and perhaps other mani-
festations of that disease. (6) The course is always protracted. Spinal
caries, even without operation, tends in the long run to become quiescent,
and if the patient is able to undergo prolonged rest, it is wonderful how
the use of the legs may be restored, even after complete paralysis. I have
seen cases recover after a complete paralysis lasting two or three years,
and have made autopsies on patients who could walk whose cord at one
spot was no larger than a quill. The Diagnosis is only difficult when
there is no curvature or other local indication of caries. Of the other
causes of extradural compression paraplegia, cancer and aneurysm are
the commonest. They occur in older subjects, and are associated with
great increase of the pain on movement. Exostoses can only be suspected
when found also in other parts of the body. These and all the other
causes of compression paraplegia are distinguished from Pott's paraplegia
by (1) the unilateral predominance of the symptoms, and (2) pain being
relatively a more prominent symptom. Von Pirquet's and other reactions
for tuberculosis may be of assistance (§ 94). For the diagnosis of the
position of the lesion, see below.

II. Oompreuion Paraplegia due to Spinal Tumour. — Tumours of the spinal cord
may be (a) extra- medullary (arising outside the spinal cord) or (fi) intra-meduUary
(arising within the spinal cord). Extra-meduUary tumours are the more common,
and it is these which produce typical compression paraplegia.

a. ExTRA-MBDULLABY Spinal Tumours may be extra- or intra-thocal, but these
two cannot be clinically distinguished. The following are the principal extra-

788

THE NERVOUS SYSTEM

[|«:

medullary tumours — syphilitio gumma, sarcoma, oaroinoma, tuberculous grovthi,
myxoma, fibroma, meningeal bsemorrhage, hydatid oysts, chondroma, exoeto&ta
lipoma (rare), or neurofibroma (springing from the nerve roots in the canal). Aneurysm.
carcinoma, and sarcoma may arise outside the vertebral column, and invade tbe
cord after eroding the vertebra, but these three lesions generally have their ovd
proper symptoms.

Functions of the Spinal Segments.

Segment of
Cord and
Spinous Pro-
cess.

II. and III. C.
Opposite

iBtC.

IV. C.
Opposite
2ndC.

V. C.

Opposite
3rdC.

VI. C.
Opposite
4tb C.

VII. C.
Opposite
6th C.

VIII. C.
Opposite
6th C.

I. D.
Opposite
7th C.

Musdes Supplied,

SterDo-mastoid.
Trapezius.
Scaleni and neck.
Diaphragm.

Diaphragm.

Deltoid.

Biceps.

Coraco-brachialis.

Supinator longus.

Rhomboid.

Supra- and infra-spi-

natus.
Levator ang. scapuls.

and
teres

Deltoid.
Biceps.

Coraco-brachialis.
Brachialis anticus.
Supinator longus

brevis.
Rhomboids and

minor.
Pectoralis (clavicular

part).
Serratus magnus.

Biceps.

Brachialis anticus.
Pectoralis (clavicular

part).
Serratus magnus.
Triceps.
Extensors of wrist and

fingers.
Pronators.

Triceps (long bead).
Extensors of wrist and

fingers.
Pronators of wrist.
Flexors of wrist
Subscapularis.
Pectoralis (costal part).
Latissimus dorsi.
Teres major.

Flexors of wrist and

fingers.
Intrinsic muscles of

hand.

Reflex.

Sudden inspiration pro-
duced by sudden
pressure beneath ihe
lower border of ribs.

Pupil reflex = 4th to
7th cervical — *.«., di-
latation of the pupil
produced by irrita-
tion of neck.

SefsstitioH*

Back of head to vertex.
Neck.

Neck.
Shoulder.
Outer arm.

Scapular reflex - 5th j Back of shoulder and

cervical to Ist tho-
racic— i.e., irritation
of the skin over the
scapula produces
contraction of the
scapular muscles.
Tapping tendon of su-
pinator longus in
wrist produces flexion
of forearm.

Triceps reflex = 6th to
6th cervical — 1.«.,
tapping elbow ten-
don produces exten-
sion of forearm.

Posterior wrist reflex
= 6th to 8th cer-
vical — i.e., tapping
tendons causes ex-
tension of hand.

arm.
Outer side of arm asd
forearm, froot aad
back.

Outer side of foream,

front and back.
Outer half of hand.

Anterior wrist reflex =
7th to 8th cervical
— ».e., tapping an-
terior tendons causes
flexion of wrist.

Palmar = 7th cervical
to 1st thoracic — <.«.,
stroking palm causes
closure of fingers.

Inner side and back ol

arm and forearm.
Badial half of the band.

Extensors of thumb.
Intrinsic hand muscles.
Thenar and hypothenar
eminences.

Forearm and band,
inner half.

Forearm, hmer half.
Uhiar dlstributloii to
hand.

1567]

COMPRESSION PARAPLEGIA

789

Functions op the Spinal Segments — continued.

Segment of

Cordt and

Spinous Pro-

ct»t.

n. to XII. D.
Opposite
j l8t to 10th
D.

I. L.
Opposite
11th D.

II. L.
Opposite
11th D.

III. L.
Opposite
12th D.

IV. L.
Opposite

12th D.

V. L.
Opposite
12th D.

I. to n. 8.

Opposite
IstL.

ni. to V. 8.
Opposite
IstL.

Musdes Supplied.

Reflex.

Muscles of baclc and

abdomen.
Erectores spinro.

Epigastric reflex = 4th
to 7th thoracic — t.e.,
irritation of mam-
mary region causes
retraction of epigas-
trium.

Abdominal = 7th to
11th thoracic — <.e.,
stroking side of ab-
domen causes retrac-
tion of belly.

nio-psoas.
Sartorius.
Muscles of abdomen.

nio-psoas. Sartorius.
Flexors of knee (Be-

mak).
Quadriceps femoris.

Quadriceps femoris.
Inner rotators of thigh.
Abductors of thigh.

Abductors of thigh.
Adductors of thigh.
Flexors of knee (Fer-

rier).
Tibialis anticus.

Outward rotators of

thigh.
Flexors of knee (Fer-

rier).
Flexors of ankle.
Extensors of toes.

Flexors of ankle, and

toes.
Peronasi.

Cremasteric = 1st to
8rd lumbar — <.«.,
stroking inner thigh
causes retraction of
scrotum.

Tapping patellar ten-
don causes extension
of leg.

Gluteal = 4th to 6th
lumbar — ue., strok-
ing buttock causes
dimpling in fold of
buttock.

Plantar reflex.

Perineal muscles.

Ankle-clonus.
Bladder and
centres.

rectal

SenioUon.

Skin of chest and abdo-
men in bands running
around and down-
wajrd, corresponding
to spinal nerves.

Upper gluteal region.

Skin over groin and
front of scrotum.

Outer side of thigh.

Front and inner side of
thigh.

Inner side of thigh and

leg to ankle.
Inner side of foot.

Back of thigh, back of
leg, and outer part
of foot.

Back of thigh.
Leg and foot,
side.

outer

Skin over sacrum.

Anus.

Periiioum. Genitals.

Symptoms of Extra-medullary Spinal Tumours, — (1) Pain radiating in the dis-
tribution of the nerve roots pressed on is usually the earliest indication, and is rarely
absent. Generally it is one-sided, round the ohest or abdomen, or down the leg ;
sometimes there is pain at the site of the tumour. (2) Progressive paraplegia starting
and predominating in one leg, and spreading upwards from the toos, more marked on
the same side as the pain, and associated with (3) ansosthesia having the same features.
Finally, both the paralysis and the anaesthesia become complete up to a definite level.
The upper limit of the ansesthesia is the best guide as to the seat of the tumour, bear-
ing in mind that the posterior roots enter the cord two or more inches (in the dorsal
region) above their entrance into the spinal canal (Fig. 165), and therefore the tumour
must be cut down upon weU above the ansasthesia limit. Of the two sub-groups of
extra-medullary tumours, extra-theoal lesions are more often attended by pain, and
intra-thecal lesions by cramps and contractures of the muscles at night, indicating
compression myelitis. The superficial abdominal reflexes are sometimes abolished
on the same side as the tumour — the aupra-umbilioal reflexes in tumours between the

THE NERVOUS SYSTEM

IfHT

eighth ftnd ninth, the infra-uinbilioal in tumoun lying between the eleventh and twdhk
doraftl vertebrs. Sometimea the nmbilicnB ia drawn towards the healtliy ndc b
meninge«l bfemorriiage the ByniptotQB of pain and p&raljBia &re of sudden onset.

The DiagnoaU of snob OMee reste on the presence and ohftrooter of the pun. tk^ l
progtessive evolution of the BjtnptoiDS. and their predominaneB on one side. Grrrinl I
meningitis " caosrs " pain on both aides. Tbo Prognoti* depends tnsinly on tk
nature and position of the tumoar, and wbother seooudai; mjelitis 1
The Trtalment (apart from anti-eypbilitio remedies) is snrgioal.

Oerr.a.
D.4.

D-tS.

L.S.

/!. SYEinaoMrRLU and Intba-hbdhllaby Tumouks (f 607) •ometimea eov
under notice for paraljrsis of the legs, and this pomplegia ma; be very peonliar aod
eontradictoi7 — namely, an atrophic paralysis astoeiaUd viilh rigidity mti incrtmtrd
knu-jerhs. The paraplegia is sometimes of an ordinary spostio type, bnt ka a rnls
this only occurs late in tlie diaease. The earliest symptoms of syringomyeli* nmallj
appear in the arras (sensory and trophic changes). But the symptoms of a>n intra-
medullary tumour necessarily differ with the position of the tumour and the ooIoBm
chiefly involved.

«]

OOMPBBaSION PARAPLEGIA

791

III. Inlnrr to Iha Bpinal Oolnmn msy oauae dinpUcement or damage to the vertebree
(frMture-dislocation ) or htemorrhage, or may initiate acute myelitiB or meniagitia
[q-v.). The gymptoDia follcwiog injury arc those either of deitruction (pnralysiB), or
irritatioD (apaem), and the hislory of the injury genernlly enables ue to make a diagnosiB.

In cases of transverse myelitis after fracture-dislacation, it was formerly taught that
the reflexes below the lesion were exaggereted unless and until the disease hod. by
dpscending. destroyed some part of tho reflex arcs. But Dr. Charllon Bostian has

CSTV.t.

0.t.
D.4.
!>.<.

CS.

D.8.

D.2.
A. to.
D.IS.
CWT.8.

D. S.
CeiT. S.
D.5.

FiB. IM.— Front via* <tf P!e- IBS.

shown that in coses of transTCTBe myelitis the reflexes below tho lesion may be absent
even without such extension downwards.

§ 558. The LoeaUsaticm of Sj^nal Leaioiu, (a) aa regards ite level, is
effected in three ways : (1) By the distribution of the motor weakness ;
(2) by the alteration of the reflexes ; and (3) by the level of the upper
limit of the pain and ancesthesia (see Head's Areas, below], (1) and (2)
are given in the table on pp. 788, 789,

792

THE NERVOUS SYSTEM

(&) The particular column which is affected can be ascertained br

studying the table in § 501.

Head's Aieai of Aiudgesia and Hyperalgesia (pp. 790 and 791) may be of some use

for the localisation of a spinal injury or lesion, but they are difficult to elicit and
define. They have been elaborated by the successive researches of James Bosi.^
James Mackenzie,^ William Thorbum,' and, more particularly, Henry Head.'* Thew
are areas of diminished or increased sensibility to pain, which correspond with certua
spinal segments, as marked in the illustration. The reader is asked to remcmbrT
in what follows that we are not now concerned with tactile sensation, but only with
sensibility to pain (algesia). A destructive lesion of a spinal segment or nerve root
is attended by analgesia of the corresponding area, an irritative lesion by hyper-
algesia. The sensibility to pain of the skin below the spinal lesion is. of ooorse.
disturbed, but to localise a spinal lesion you should carefully test the sensibility from
above downwards with the point of a pin, and you will find an abrupt margin of nor^d
sensibility to pain at the upper border of the affected area. The important questioii.
really, is to what level does the sensibility to pain remain normal. Head's areas wrstt
discovered mainly by the investigation (1) of cases of injury to the spinal nerve roolB,

(2) cases of visceral disease associated with soreness of the skin or reflex pain, and

(3) oases of herpes.

Table op Visceral Disease in Eelation to Superficiai-
Tenderness or Reflected Pain (Dr. Henry Head).

Heart, Ventricle .... Dorsal 1 (?), Dorsal 2, 8, 4, 5.

Auricle . . . . . . Dorsal 6, 6, 7, 8, and (?) 9.

Aorta, Arch Cervical 8 and 4, Dorsal 1, 2, 8, 4.

Dorsal Aorta Dorsal 6, 0, 7, 8, 9.

Abdominal Aorta .... Dorsal 10, 11, 12, and Lumbar 1.

Lungs Cervical 8, 4, Dorsal 8, 4, 6, 6, 7, 8, 9.

(Esophagus Dorsal 6, 6, 7.

Stomach Dorsal 6, 7, 8, 9, 10.

Intestine —

1. Duodenum to Sigmoid Flexure . Dorsal 10, 11, 12.

2. Rectum Sacral 2, 8, 4.

Liver and Gall Bladder . Dorsal 7, 8, 9, 10. (Right side.)

Kidney and Ureter .... Dorsal 10, 11, 12, Lumbar 1, Lumbar 2 and Occipttal.

Bladder Sacral 2, 8, 4.

Prostate Sacral 2, 8, 4, Dorsal 10 and (?) 11 and Occipital.

Testicle Dorsal 10.

Epididymis Dorsal 11 and 12.

Ovary Dorsal 10.

Uterine Appendages .... Dorsal 10, 11, 12, Lumbar 1, and (?) Lumbar 2.
Cervix Uteri and Lower segment of

Uterus Sacral 2, 8, 4.

Area on the Scalp,

Fronto-nasal.
Mid-orbiUl.

Fron to- temporal.

Temporal.

Vertical.
Parietal.
Occipital.

Area on the
Trunk.

Cervical 8.
Cervical 4.
Dorsal 2.
Dorsal 3.
Dorsal 4.
Dorsal 6.
Dorsal 0.
Dorsal 7.

Dorsal 8.
Dorsal 9.
Dorsal 10.

Organs in relation with these Areas.

Lung (Apices), Stomach, Liver (Occipital).
Heart (Ventricle), Aortic Arch, Lungs.

Lung, Heart.

Lungs (lower lobes), Heart (Auricle).

Lungs (lower lobes), Heart (Auricle), Stomach (Cardiac

end), Liver (R. side).
Stomach, Liver, and Gall Bladder, Lungs.
Stomach (Pyloric end), Liver.
Intestine, Liver, Ovary, Testis, Stomach (Occipital).

* Brain, January, 1888, part x., p. 333 ; and " Diseases of the Nervous System.

2 Brain, 1893, part xvi., pp. 321 and 515 ; and Med. Chronicle, August, 1892.

3 Brain, 1893, part xvi., p. 365.

* Ibid., 1893. part xvi., p. 1 ; 1894, part xvii.. p. 339 ; 1890. part xix.. p. 153.

§659] ACUTE TRANSVERSE MYELITIS 793

^ These areas may also have two other possible uses. In certain vtaceral d%8ease$

groups of these areas are apt to be the seat of tenderness, and even pain, which is
probably of a reflex nature ; single area tenderness is practically never met with. To
test these areas the rounded head of a lady *s hat-pin is best, its smooth surface evoking
the sensation of sorenesss. The various organs stand in connection mainly with the
areas as shown in table on p. 792, the areas being those indicated in the figures (Dr.
Honry Head in " Quain*s Dictionary of Medicine,'* third edition, p. 1138). There are
also certain smaller spots of maximum tenderness to which a patient chiefly refers his
pain, which remain tender longer than the rest of the skin around. The whole of this
question is at the present time one of more scientific than practical interest.

Head's areas also correspond to the areas affected with attacks of herpes (zoster),
which is now almost certainly proved to be due to some irritative lesion of the posterior
root or root-ganglion, or of the corresponding spinal segment. It was, indeed, the
careful study of a large number of cases of herpes and the careful examination of
twenty-one fatal cases which enabled Dr. Henry Head to map out these algetic areas
with the precision which he has achieved.

§659. IV. Acute Transyerae Myelitis is a transverse softening of the
cord, due to inflammation, thrombosis, or some other similar vascular
lesion, characterised in typical cases by the completeness of the loss of
sensation and motion below the lesion, by the " girdle " pain, and by the
tendency to bedsores and sphincter troubles. The dorsal region is the
most usual position of the lesion. This paraplegia at first is flaccid.

Symjftams. — 1. The advent may be as sudden as apoplexy, or it may
occupy a few days. Generally it is attended by slight pyrexia.
According to the severity of the onset, cases are described as acute or
subacute. 2. The " girdle " pain is a characteristic symptom, consisting
of a feeling as of a constricting cord around the trunk opposite the upper
limit of the lesion. There is also a band of h3^er8Bsthesia and increased
superficial reflexes in that position. Below this level the sensation and
superficial reflexes are lost. 3. Paralysis and anaesthesia involve the
whole of both legs. The paralysis is flaccid in the early stage, but the
muscles gradually become stifE in the course of a few weeks owing to the
descending sclerosis. There is no atrophy and no Erb's reaction (§ 516),
unless the cervical or lumbar enlargements are involved, when the paralysis
is of an amyotrophic type (§ 600). The extent of the paralysis, and
whether the trunk and arms are involved, depend upon the situation
and extent of the lesion. Involuntary startings of the legs are common.
4. The deep reflexes below the lesion are at first abolished, but they rapidly
return (except when the lumbar enlargement is involved), then become
exaggerated and accompanied by ankle-clonus. 5. Retention of urine
and f SBces is present at the onset ; later on evacuation takes place without
the patient being conscious of it. If the lumbar centres are involved,
there is true incontinence from the onset. Bedsores nearly always super-
vene, in spite of the best nursing, especially in cases where the lumbar
region is involved. 6. The course is always rapid, and there is but little
hope of regaining full use of the affected limbs. In an ordinary case
sensation may return in three to six months, and motion to some extent
in sixjto eighteen months. The higher up or lower down the lesion is
situated in the cord, the more grave the prospect. When the cervical

794 THE NERVOUS SYSTEM [ §

region is affected, death often odours in a few days from pneamonia, or
paralysis of the respiratory muscles. When the lower dorsal region b
afiected, death may ensue from cystitis, surgical kidney, or bedsores.

The Diagnosis in typical cases of myelitis is not, as a rule, difficult, os
-account of the girdle pain, rapid involvement of the bladder and rectum,
and the completeness of the paralysis and anaesthesia. Compression para-
plegia presents pain, is of more gradual onset, and there may be iinilatoaJ
predominance. The pyrexial onset, with headache, etc., aids in the diag-
nosis from haemorrhage and embolism (see below).

Causes, — ^Acute myelitis is more common in males between ten and
forty years of age. Among the causes may be mentioned injury, bsmor-
rhage, extension of inflammation from the meninges, compression, over
exertion, exposure, suppression of the menses, and various toxic blood
states. Some cases have been associated with syphilitic disease of th«
arteries.

Ohronio Traniven e Myelitii may supervene on the acute, or it may be ohzonic from
the onset. It presents the same characteristics as acute myelitis in a lesser degree —
complete loss of motion and sensation in both legs, girdle pain, involvem^it of Maddw
and rectum, and tendency to bedsores. At first, before the rigidity saperrenes, it
may resemble multiple neuritis.

Acute diffuse or Central Myelitii is a rare form of acute myelitis, accompanied bj
marked pyrexia, widespread paresis, and anaesthesia (§ 573). It rapidly spreads to
the whole cord, and is generally fatal.

§ 690. Vascular and other Lesions of the Spinal Cord. — V. Hsmoirhace into tiie
spinal cord is said by most observers to be very rare, unless preceded by some oon-
genital cystic defect or some degenerative or neoplastic lesion, such as ^oma.^ Tie
exacerbations of symptoms in syringomyelia are believed to be due to hemorriiap,
Intra-medullary h»morrhage is characterised by the sudden onset of oom|dete motor
and sensory paralysis, accompanied at first by loss of superficial and deep reflexes,
which return in an exaggerated degree a few days later imless the lumbar enlargement
is affected. It presents most of the symptoms of acute myelitis, from which it
only be differentiated by its instantaneous occurrence, attended sometimes by
localised pain. HsBmorrhage into the spinal membranes has similar symptoms,
panied by pain due to pressure on the nerve-roots, as in other extra-medullary tmnoozB
(§ 667).

VI. Embolism of ths Cord is rare. The patient complains of a severe ** shock in
the spine,*' followed by sudden and complete paralysis within a definite area, whidi
corresponds with the position of the lesion. Cardiac disease or the other oanses of
embolism are in operation.

Vn. Spinal Pachymeningitis (Chronic Spinal Meningitis, Meningeal Thiofeening),
may give rise to paraplegia, with stiffness of the legs, of very gradual onset and pro-
longed course. This morbid condition is said by some to be infrequent, and not to
give rise to any obvious symptoms, but at the Padding^n Infirmary I had no diffi-
culty in collecting seven cases verified by autopsy in the course of two or three yean.

1. The leading Symptom of this form of paraplegia is pain shooting down the nerree
of the leg and elsewhere, aggravated by any movement of the back ; sonketimef
extremely severe, and accompanied by tenderness of the spine. 2. Stiffness and weak-
ness of the legs, involuntary twitchings and increased reflexes were pres^it in my
cases as the disease progressed. 3. Patches of hypersBsthesia and ansBsthesia wen
occasionally present, and in some there was a progressive atrophic weakness of varioQt
muscles due to the constriction of the nerve roots. 4. In certain cases the thecal
mischief spreads to the spinal cord, and various symptoms may arise according to the

^ See an interesting clinical lecture by Sir William Gowers in the Lamcti, 1903,
vol. ii., p. 993.

§ 660 ] VASGULAB AND OTHER SPINAL LESIONS 796

column involved. When the posterior oolumn is affeoted, as in the cases alluded to
in I 579, the patient may present all the symptoms of tabes dorsalis. The course of
my oases varied from two or three to about ten years, death supervening from some
intercurrent malady.

The Gau8€Ui<m is obscure. Syphilis was present in the history of some, but none
of the oases seemed very amenable to anti-syphilitic treatment.

Oervioal Pachymeningitii (H3rpertrophio Cervical Meningitis) is the same anatomical
condition as the preceding, limited to the cervical region. It was first described by
Professor J. M. Charcot. Pain and atrophic paralysis affect the arms, and 8ub«
sequently spastic paraplegia, due to descending latend sclerosis.

VIIL Ohronio Syitem Lefiom. — ^Three degenerative diseases of the central nervous
system of fairly common occurrence may first come under notice for weakness of the
legs— disseminated sclerosis, general paralysis of the insane, and occasionally tabes
dorsalis. Each have other and more characteristic symptoms, and will be dealt with
elsewhere. There are also five other rarer conditions, in which stiffness of the legs,
due to lateral sclerosis, is a leading feature— primary lateral sclerosis (lateral sclerosis
only) ataxic paraplegia (lateral and posterior sclerosis), amyotrophic lateral sclerosis
(sclerosis of the lateral column and anterior horns), infantile cerebral and spinal para-
plegia, and toxic sclerosis (see Fig. 148 in § 602).

IX. Primary Spastio Paraplegia (Synonyms: Primary Lateral Sclerosis, Primary
Sclerosis of the Grossed Pyramidal Tracts, Erb's Paraplegia,^ Tabes Dorsalis Spas-
modique). — ^Lateral sclerosis on one or both sides is commonly met with as a spreading
downwards from a localised disease in the brain or cord, but the primary spastic para-
plegia consists of sclerosis of these columns without any primary disease above. Some
deny the existence of a primary lateral sclerosis, and, personally, I regard the disease
as extremely rare, though some cases of spastic i>araplegia seem to baffle all inquiries
as to the primary or initiating lesion. (1) The onset is extremely slow and insidious,
and the course is slow and painless, extending over many years, twenty or thirty
being said to be not uncommon. (2) Ihill acldng and stiftiess rather than absolute
wea^ess is the leading symptom, and this gradually results in a stilted walk, till finally
the patient walks on tiptoe without bending the knees, which is very characteristic.
In advanced oases there is cross-legged progression, because the adductors are specially
involved in the rigidity. Both legs are involved, though one may be a little worse
than the other. Increased knee-jerk and ankle-clonus are present, as in other cases of
lateral sclerosis. (3) The other symptoms consist of a series of negative points — viz.,
no disturbance of sensation, no sphincter trouble, no bedsores, and no alteration in
the eleotrioal reactions are the rule. In the later stages of the case the arms may
become stiff.

EUUogy, — The patients are usually from thirty to forty years of age. Deficient
blood supply has been suggested, and syphilitic toxsamia, leading to disease of the
arteries, is a possible cause. Chronic alcoholism and other toxic agencies have been
suggested. The author has seen cases indistingroishable from Erb's primary spastic
paraplegia completely recover when the oral sepsis from which they suffered had been
oured.

X. Atazio Paraplegia, or postero-extemal sclerosis, is a rare disease, due to primary
sclerosis in the posterior as well as the lateral columns. There is defective co-ordina-
tion of the movements and ataxy, but none of the other symptoms belonging to loco-
motor ataxy. The knee-jerks are increased, and there is stiffness of the legs. This
disease is met with chiefly in men of middle age, but much the same spinal lesions
occur in Friedreich's disease — t.e., the hereditary ataxy of childhood.

XI. Amyotrophic Lateral Soleroiis (Charcot) is a rare condition, due to disease
affecting both the anterior horns and the lateral columns. The symptoms are usuaUy
confined to the arms for a time, and the disease is therefore described under Brachi*
plegia, § 667.

^ Erb has described under the term " syphilitic spinal paralysis " an insidious
spastic paraplegia, which he regards as distinct from primary spastic paraplena ;
but in the author^s view this is practically identical with the above (iSrans. West
Lend. Med. Chir. Soc., about 1902).

796 THE NER VO US 8 Y8TEM [ §

XII. Infantile Cerebral and Spinal Paralyiee (including birth palsy, spastio diple^
Little's disease). — ^Tbe cerebral leg centres lie on tbe mesial aspect just below the
margin of each hemisphere, and during difficult or prolonged labour these are lifthie
to damage by compression of the hemispheres and meningeal hemorrhage. In other
oases diffuse atrophy has been found, or porenoephalus. When the condition oecon
in prematurely bom infants, it is believed to be due to defective development of tk
pjrramidal tracts. Consequent on any of these lesions degenerative sclerosis teb'>
place down the crossed pyramidal tracts, and spastic paraplegia results. Nothing
perhaps, is noticed until the child begins, or ought to beg^n. to walk, which it is Uio
in doing ; then the legs are stiff, and signs of lateral sclerosis are present. Hie irms
also may be involved — spastic diplegia. A limited athetosis or a more geoenlisec
chorea spastica may ensue. In all these varieties there is very often a history of coo-
vulsions in infancy and a condition of mental deficiency. In other oases (hereditur
spinal spastic paraplegia), however, the child is bom with a stiAiees of the legs, bit
without any mental symptoms or backwardness, and in these oases there has poaably
been an injury to the cord at birth. Such patients may live bedridden to a consider-
able age — ^forty or fifty years. Some recognise a genuine hereditary form of ti»
malady, which affects several members of a family, in whom some developments]
defects may be assumed to exist.

XI IT. Tozio Combined Sclerosif . — Of late years sclerosis of the cord has been ssbo-
oiated by the labours of Taylor,^ Russell, and others with various blood conditions,
such as diabetes, pernicious ansamia, leuksamia and pellag^. The 83rmptoin8 tsit
according to which of the columns is mainly affected, but paraplegia is genendly in-
complete in degree, and is sometimes associated with ataxy and numbness. TV
sclerosis affects chiefly tht posterior and lateral columns of the cervical and thonck
regions. It may be recognised from similar spinal affections by the previous ocenr-
rence of one of the diseases named or some other toxic disorder, pernicious ansmii
being, perhaps, the most typical instance.

Progressive stiffness of tiie legs, resulting in spastic paraplegia, is the leading symp-
tom of lathyrism (lupinosis) — i.e., poisoning by the use of meal derived from tlif
seeds of the chick-pea (lathyrus sativus and 1. cicera) mixed with other meal in Uk
preparation of bread. The arms are very rarely affected. It is met with in Inda
(chiefly), Algeria, and probably elsewhere. The anatomical condition is not known,
but it is probably a toxic sclerosis.

TrtakntnL — Resection of the posterior nerve roots' has given good resolts in cues
of spasm due to disease of the upper neuron. The excess of sensoiy impulses is then
no longer inhibited by the cerebrum, and the muscles undergo reflex contraction.
Division of the posterior nerve roots cuts off the excessive sensory stimuli, the nras-
cular spasm relaxes, and a certain amount of voluntary movement, depending upon
the degree of impairment of the pjrramidal motor tracts, retums. The operation
has been successfully employed in cases of little's disease, Erb's spastic parapkftt.
Pott's disease, and syphilitic spastic paraplegia. The treatment is not advissd in
cases of mobile spasm.

Group B. The Lower Neuron or Flacdd Paraidegias constitute a more
limited group than the upper neuron paraplegias, and are distinguished
from them by the four following features : (1) The paralysis is flaccid— at
any rate, for a considerable time ; (2) muscular wasting is a mariced
feature, and is attended by (3) characteristic electrical changes ; (4) the
deep reflexes are absent. This group is distinguished from the functional
paraplegias (Group C) by the steady and progressive course of the lower
neuron paraplegias, by the muscular wasting, and the electrical changes.
They are as follows :

1 James Taylor, Roy. Med. Chir. Soc. Trans., 1895 ; J. R. Russell, the loMcH.
1898.

2 Professor Forster. the Ijancef, July 8, 1911.

§ 561 ] MULTIPLE PERIPHERAL NEURITIS 797

k I. Multiple peripheral neuritis § 561

! II. Beri-beri (which is a form of the preceding) § 562

^ 111. Anterior poliomyelitis § 601

I IV. Acute transverse myelitis (at the outset) § 559

I V. Landry's paralysis § 576

1 • VI. Syringomyelia and intra-modullary tumours, intra-meduliary h»mor-

rhage and embolism (sometimes) § 607

§ 561. I. Multiple Peripheral Neuritis (Synonyms : Multiple Neuritis,
Polyneuritis) is a symmetrical inflammation of the peripheral nerve-
trunks (due to a toxaemia) attended with pain and tenderness along their
course, resulting in paresis and anaesthesia. This disease is more or less
general in its distribution, but the paresis may predominate in the legs,
and the patient frequently comes under our notice for paraplegia.

Symptoms, — The onset may be acute, subacute, or (more usually) chronic.
Some observers make three varieties, according to whether the motor,
sensory, or ataxic symptoms predominate. In acute cases pyrexia may
be present. (1) There is generally a premonitory stage in which there are
numbness, tingling, cramps and twitchings in the legs or arms. Pain forms
a prominent feature in all cases of neuritis, the degree varying according
to the acuteness of the process. The pain shoots along the course of the
nerves, is symmetrical in distribution, and increased by movement.
(2) There is also deep-seated tenderness along the nerve-trunks and in
the muscle substance, especially in the calves. These sjnnptoms are soon
followed by (3) flaccid paresis attended by more or less atrophy. The
extensors are more afiected than the flexors, and the patient has a charac-
teristic foot-drop (or wrist-drop), and a difficulty in raising the legs in
mounting stairs. (4) The electrical reactions vary, but there is in all cases
a diminution of faradic reaction. In many cases there is also a diminution
to both galvanic poles (a condition which one does not obtain in anterior
poliomyelitis), while in a few cases there is also typical Erb's reaction
(§ 516), and A.C.C. is greater than K.C.C. (5) The superficial and deep re-
flexes are diminished or disappear. (6) Anaesthetic and hypersesthetic
areas at the termination of the sensory nerves in the legs and arms may,
with care, be revealed. Often there is a patch of anaesthesia surrounded
by a zone of hyperaesthesia. Bladder and rectal troubles and bedsores
are only met with at a very advanced stage, though in alcoholic cases
with the dull mental state the excretions may be passed in bed. It is an
interesting fact that the nerves involved vary somewhat with the toxic
agent in operation, as though the latter had some selective proclivity.
Thus, alcohol and beri-beri affect mainly the legs ; lead, the arms ; diph-
theria, the throat and neck muscles ; while arsenic appears in a few cases
to affect mainly the trophic nerves of the skin. In lead paralysis the toxin
selects the motor fibres of the musculo-spiral nerve, and produces double
wrist-drop. Accompanying severe alcoholic cases is loss of memory,
apathy, and sometimes delirium.

Peripheral neuritis may have to be diagnosed from tabes and polio-
myelitis, It is recognised from the former by the actual muscular weakness

798 THE NERVOUS 8 Y8TEM [ f Itt

and the tenderness present, the high-stepping walk, and the absence (rf
pupil changes ; and from the latter by the sensory changes and the age of
the patient. The neuralgic pains may have to be differentiated from
other causes of '' pains in the limbs " (§ 422) ; and, lastly, the disease will
often need to be distinguished from the other flaccid lower neuron pareses in
this group, and from syringomyelia (§ 607). The acute febrile cases are hard
to distinguish from Landry's paralysis and poliomyelitis in adults (§ 576).

Prognosis. — Multiple neuritis is essentially a chronic afEection, but has
a distinct tendency to recover. The chief danger rests in the involvement
of certain nerves, such as the pneimiogastric in diphtheritic paralysk,
when sudden death may ensue. The acute febrile cases may die in a week
from involvement of the respiratory muscles or cardiac paralysis, but, in
general terms, a large proportion of cases of multiple neuritis get well
under appropriate treatment in the course of three to about twelve months,
if the cause in operation be removed. Deformities from contractures may
result in severe cases.

Causes, — Multiple neuritis may occur in either sex and at any age, bat
is most common in adults from twenty to fifty. Women are slightly
more afiected than men. There is always some toxaemia (or blood condi-
tion) in operation, and the commonest of these in adults is alcohol ; in
children, diphtheria. The other causes are : (a) Among the hetero-toxitu—
lead, arsenic, silver, mercury, ether, bisulphide of carbon and naphtha;
(6) among the microbic toxins — influenza, tuberculosis, leprosy, enteric
fever, variola (?), rheumatic fever, scarlatina, and other infectious fevers ;
(c) peripheral neuritis may supervene in some autotoxic conditions — c^..
gout, diabetes, cancer, oral sepsis, beri-beri, and pernicious ansemia. And
an attack has sometimes followed over- exertion or exposure. Traumatic
cases come under the head of monoplegias.

TrecUment, — The causes must be sought for and removed — e.^., alcohol
must be absolutely forbidden, and any gouty or other diathesis must be
treated. Rest is the cardinal feature in all treatment, and merely remain-
ing in bed will do much to cure. Prevent contraction of the paral3rsed
limbs by sandbags. Iodide of potassium and quinine are undoubtedly of
use for the elimination of toxins, whether it be alcohol, lead, gout, or oUier
kind. When the acute and painful stage has subsided, galvanism is very
valuable, and its systematic use, with or without faradism and massage^
will hasten the restoration of the muscular weakness.

§ 662. II. Beri-Beri frequently comes under notice for paraplegia, sometiineB for
dropsy of the legs. The disease is endemic or epidemic in certain localities. Tbe
paraplegic form is now recognised as duo to a peripheral neuritis.

The Symptoms of bori-bcri belong to two classes : (a) Those referable to the nemo-
muscular system (the paralytic type) ; and (6) those reiforable to the vaso-motor systrm
(the (edematous type). Either may occur alone, but more often both are pr^aeoK
the paralysis predominating. The onset may be sudden or gradual, with prodromato
of languor, pains, and slight dyspnoBa.

In (a) there is no oadema. The patient may bo so thin and emaciated thftt the
condition is caUed ** dry beri-bori." The first symptom is a difficulty in walking, with
the characteristic high-stepping g^it of foot-drop. The knee-jerk is soon lost, and

§668] BERl'BEM— FUNCTIONAL PARAPLEGIA 799

the muscular paralysis may extend from the legs to the arms, diaphragm, interoostals,
and larynx. There is cutaneous anaesthesia, occurring first in the legs, and sometimes
not spreading farther ; at the same time there is great muscular tenderness, especially
noticeable in the calves. The sphincters are not affected. The heart is dilated
towards the right, but cardiac symptoms play a minor part in this variety.

In (6) the characteristic symptoms are great dyspnoea and oedema, which is especially
8oen in the legs. Where dropsy is extreme tho condition is called ** wet beri-beri,"
the heart is dilated, especially to the right, with changing bruits from day to day.
The digestion may remain unimpaired, and there is no fever.

Diagnosis, — Bein-beri has to be diagnosed from alcoholic and other forms of peri-
pheral neuritis, and here the oedema, and the constant involvement of the heart in
beri-beri are important. It may be diagnosed from locomotor ataxy by the absence
of the characteristic ocular and other symptoms which occur with that affection.

Prognosis. — In an epidemic the mortality may rise to 50 per cent., but normally
only 10 per cent, of the cases end fatally. Death occurs usually from cardiac failure
or asphyxia, and is thus very frequently sudden and unexpected. A favourable case
runs its course in a few weeks, but usually the disease lingers on for months, especially
if the patient continue to live in an endemic area. Serious complications may arise
in the form of oedema of the lungs or effusion into the serous cavities.

Causes. — Recent work has proved that the disease is due to a diet consisting largely
of polished rice. Some nutritive constituent present in the coating of the rice grains
is removed by the process of polishing. Beri-beri occurs in Japan, China, the Malay
Peninsula, and other parts where polished rice is much eaten. Treatment is sympto-
matic, and if symptoms of great venous obstruction occur with intense dyspnoea,
bleeding must be at once resorted to. Prophylactic treatment consists in the avoidance
of polished rice. Where this is impossible its injurious effects are apparently to
some extent counterbalanced by the addition to the diet of meat and peas.^

§ 568. Other CaaiM of FUccid Paraplegia.— III. Acute Anterior Poliomyalitifl at the
onset may take the form of a paraplegia, but it more often affects one of the legs or
one of the arms. In the course of a week or two it usually settles down into one limb,
one segment of a limb, or one set of muscles. It is almost certainly confined to children!
It is described under Amyotrophy (§ 601).

IV. Acute Transverse Myelitis (§ 559) is at the outset a flaccid paraplegia, but the
paralysis is not atrophic excepting in the unusual event of the lesion occupying the
cervical or the lumbar enlargement. The paralysed limbs become rigid, and the
reflexes return in the course of a few weeks.

V. Landry's Paralysis is also a flaccid paralysis (§ 576). It is a rare disease, re-
sembling acute myelitis in some respects, only no gross lesions after death have boon
found. There is a sudden onset of flaccid paralysis of the legs, followed by rapid
extension to the muscles of the trunk and arms, and generally a rapidly fatal termina-
tion. A tetracoccus has been described in connection with the disease (£. F. Buzzard),
but its etiological significance has not yet been established.

VI. Syringomyelia and Intra-mednllary Tumours and HsBmorrhage may come under
notice as paraplegia with flaccidity, and very often with a oontradictory increase in
the knee-jerks ; but on further examination this will be found to be preceded by the
arm symptoms (§ 607).

Group C. Fonctioiuil ot Variable Paraplegias.— When an organic lesion
is present, whether it be in the upper or lower neuron, we get a continuous
or rather an unvarying, paralysis which progresses steadily for better or
worse. But the leading feature of functional paraplegia is (1) that it
varies in intensity and sometimes in its other features from day to day:
(2) The paralysis is less marked, it is a paresis rather than a paralysis, and
it does not clearly conform either to the upper or lower neuron type ; (3) it
is accompanied by other evidences of the causal condition.

* Tropical Joum. of Med. and Hygiene, November and December, 1911.

800 THE NEB VOUS 8 Y8TEM f §f M4|> M

The principal varieties of variable paraplegia are —

I. Hysterical paraplegia.
II. Railway spine.
III. Paraplegia after fevers.
rV. layer's paralysis.

V. Reflex paralysis.

§664. Hysterical Paraplegia is undoubtedly the commonest, and nuj
be taken as the type, of functional paraplegias. The nature of the lesioii
yfe do not know, and so variable are its clinical features that we have U>
rely mainly upon the fact of its occurrence in a female who is the subject
of other hysterical manifestations. (1) The paraplegia is generally of
sudden onset, and not infrequently dates from some hysterical seizure. 1
once saw a healthy girl coming out of church in front of me drop wiUi tke
onset of the disorder. It is rarely complete, and varies in intensity from
day to day. Sometimes it is rigid, but almost as often flaccid, and tk
patient drags her feet along in a characteristic way, resembling peiipherai
neuritis in the presence of foot-drop. (2) The paralysis and the other symp-
toms are inconsistent and evanescent. Thus, there may be h3rpenB8tJiesa
in one leg, ansesthesia in the other, and the two may change places or
disappear from day to day. All the symptoms may disappear rapidly,
though 1 have observed rare cases of several years' duration.^ (3) The
muscles do not waste nor lose their electrical contractility. The deep
reflexes may be imchanged, but I have generally found them exaggerated.
The plantar reflex gives a normal flexor response showing the absence of
organic disease of the spinal cord (Babinski). (4) Incontinence of urioe
or fsdces is very rare, and bedsores never occur with good norsing.
(5) Other evidences of the hysterical diathesis are present.

In the Diagnosis it is well to remember that the patient is practicaUy
always a female, though male cases have been recorded.^ In myelitis
there are trophic changes, girdle pain, and incontinence — features wliidi
are wanting in the functional variety. Other organic paraplegias are
identifled by their continuous and progressive character, and by the pres-
ence of ankle-clonus and Babinski's sign. These latter are regarded »
absolutely conclusive of organic disease, but there is a kind of spurious
ankle-clonus in many cases of hysteria which is only distinguished with
difficulty from the ankle-clonus of organic disease. The Causes and
TrecUment are dealt with elsewhere (§ 524).

§ 565. U. Railway Spine and other Functional Paraplegias.— A seyere shock or

injury to the spine, such as ooours in railway accidents, may cause (1) a direct mjvrj
to the cord, such as hasmorrhage, laceration, or concussion ; (2) the shook may deter-
mine the occurrence of some degenerative lesion which does not come on pechapi
for some months, such as disseminated sclerosis, tabes, or spastic paraplegia ; or (3) a
form of painful paraplegia may ensue, not coming on until some days, weeks, or eveo
'months after the injury. It is with this last we are now concerned. Some, like
Erichsen and Gowers, regard it as an incipient myelitis; others, like Herbert Page,
maintain that it is due to a frmctional change (? vascular). The symptoms oonaist ol

^ Trans. Clin. Soc. Lond., vol. xxiL, and the Lancet, 1901, vol. i.
* The Lancet, 1889, vol. i. and vol. ii., p. 792.

§666] PR0QN08I8 OF PARAPLEGIA 801

(1) severe spinal pain and tenderness (spinal neuralgia) and obscure peripheral sensa-
tions, Buoh as ting^ings, twitohings, or numbness in the legs. (2) A paresis or pseudo-
paralysis, whioh Page believes may be due to the fear of pain produced by movement.
(3) ladder symptoms are sometimes present, such as frequency of micturition or a
dribbling at the end, or a difficulty in defsecation. These oases are very difficult to
treat successfully. Best, with change of scene and occupation, are the main elements.

III. Paraplegia alter Fevers. — AnsBmia and congestion of the cord are said by some
to give rise to no symptoms, but by others are said to cause tingling and cramps,
especially at night, and a variable degree of weakness of the legs, chiefly on exertion.
General anaemia of a severe type has been shown to cause actual sclerosis of the cord
(see Toxic Sclerosis). The paraplegia following beri-beri and most fevers is due to
peripheral neuritis, sclerosis, or myelitis, but that whioh is especially liable to occur
after jun^ lever is held by Indian authorities to be due to anaemia of the oord. All
these forms are characterised mainly by (1) the circumstances under which it occurs,

(2) the paralysis being incomplete and usually transient.

IV. DlTer'i Paraljiis (Synonyms : Caisson Disease, Compressed Air Illness) is a
paraplegia which occurs in men who work under water or tunnel under the ground at
high atmospheric pressures. It is due undoubtedly not so much to the pressure they are
subjected to, as to the sudden release of that pressure, which produces congestion of
the cord, with liberation of gas from the blood. In fatal oases hsBmorrhage and myelitis
have been found. This was well illustrated in a case shown by Dr. Robert Maguire at
the Medical Society.^ The patient had had six or seven previous attacks, and the last
was brought on entirely by his sudden rush to the surface from a depth of 150 foet —
that is to say, from a pressure of 90 pounds to the square inch to one of 15 pounds to
the square inch. The paresis is never quite complete, but is of sudden onset when the
patient returns to the normal atmospheric pressure. It usually affects the legs, rarely
the arms to any extent. Anaesthesia, severe pain, and sphincter paralysis only occur
in the graver cases. Auditory vertigo, haemorrhage from the nose, lungs, and other
parts sometimes occur. The prognosis is favourable in most cases ; pain and paresis
pass off in a few days to six weeks. A few cases have died.

Treatment. — Curative measures consist simply of rest and the avoidance of alcohol
— a failing to which most of these workmen are addicted. Ergot has been recom-
mended. Preventive treatment consists in following out precautions for gradual
decompression. Men employed in diving or in tunnel working under pressure should
be compelled to undergo a very gradual process of decompression. Dr. Snell recom-
mends^ ten minutes' decompression for each atmosphere of pressure.

V. Reflex Paraplegia is a variety which some do not admit, but there appear to be
certain very rare cases associated with gastro-intestinal, uterine, or other irritation. It
was first described by Trousseau. After operations on the anus there may be weakness
of the legs and inability to pass urine for days. The loss of power appears to be never
quite complete. The only means of identification consists in the presence of a reflex
cause and the disappearance of the paralysis when this is removed. Some cases sup-
posed to be of reflex origin have been found to be due to neuritis ascending to the cord.
§ 566. The Prognosis and Treatment of Paraplegia. — Oeneral Bemarks on the Prog-
nosis of ParaplegitL — Paraplegia is always a serious symptom, not only because it
prevents locomotion, but because it indicates structural or functional disease of that
important structure the spinal cord. In general terms ( 1 ) all functional disorders are
more favourable than organic ; (2) flaccid paraplegias tend to run a quicker course
either towards recovery or death than rigid paraplegias ; (3) the most unfavourable
signs are bedsores, and the implication of the bladder and rectum. The different
forms of paraplegia may be grouped for the purposes of prognosis into four groups
(see table on p. 802). The presence of complications adds to the gravity of any case.
Many oases die of cystitis and pyelitis or the chronic septicaemia which results from
bedsores ; others from pneumonia or other complications. Finally, efficient or in-
efficient nursing is an extremely important factor in the prognosis, for these cases
constitute the test and trial of all that makes for efficiency in nursing.

1 The Lancet, April 14, 1900.

^ " Monograph on Caisson Disease," by Dr. £. H. Snell. H. K. Lewis, London, 1896.

d02

fHB NSRV0V8 SYSTEM

Prognosis of the Different Forms of Paraplegia.

tiJ

fpx^m* M&^A ««i.^/i2i^ Th09$ which gtnt"

^l^J JS^mX I ^««y tmninau in
rewotf eampuu&if, paetul recovery,
eUher epontane- , JSktr «i>o»Tflj»«^

Hysterical and the
other yarieties of
functional para*
plegia.

Peripheral nenritia.

Some caaea of Pott's
disease.

Non-malignant extra-
mednllary tomours.

Paraplegia after fe-
vers.

Toxic sclerosis.

Most cases of Pott*s
disease.

Anterior poliomye-
litis.

Thou toMeA tofi4 to
heicome ckrotUe and
incurabUf hut not
fatal.

Dorsal myelitis.

Embolism.

Some spinal injnries.

Chronic spinal men-
ingitis.

Hemorrhage.

Primary lateral scle-
rosis.

Ataxic paraplegia.

Amyotrophic lateral
sclerosis.

Infantile cerebral and
spinal pan4>ls8i^

Thorn
mfttlml

Malignant and int-
oeasible tmnooi-

Acnte cervical «
lumbar myelitis.

Some caaea 6t
rhage.

Malformatloo.

The TreatmetU of paraplegta, excepting in " functional " caaee, ia not veiy hope^
for a serioualy damaged portion of the cord can never be fully restored. There sn
three indications : To remove the cause, to prevent complications, and to restore tt<?
functions, (a) To remove the cause : (1) Anti-syphilitic treatment, and partknUriy
iodide of potassium, should be employed at once in all possibly syphilitic caaea ; 60 u
180 grains of the iodide should be given daily. It will probably not restore a dkWM^
segment of cord, though Brown-S6quard advocated its use in what were called ca»
of atrophic softening. In some chronic cases it certainly seems to promote tbe
absorption of inflammatory products. (2) If the existence of inflammation or eoe-
gestion of the cord be suspected, belladonna and ergot may be given ; expcrimecitslh
these remedies produce contraction of the vesseb of the pia mater. Rest and tk
prone position, the patient lying on the stomach, are also of advantage. In eases d
congestion or myelitis nux vomica, opiates, and galvanism should be avoided. When
hsemorrhage is suspected, prolonged absolute rest in the prone position is neoessaiT.

(3) Oounter-irritation, I believe, might with advantage be used more often than it b
especially in the upper neuron group — blisters to the spine, frequent cupping, hxi
douches, frictions, mustard or ung. hyd. iod. rubbed into the spine. In chronic cask
the best treatment, in my experience, is the " coup de fer " of the French — that a w
say, dotting the point of a Paquelin thermo-cautery down the spine every other day.
Several cases of sclerosis under my care have derived advantage from these metho^ii.

(4) Surgery comes to our aid in cases of Pott's disease, injury* maUonnAtiona. sad
some tumours. Certain of the causes require special treatment. In Poits diman
rest in a prone or supine position affords a good chance of complete reooTery (he*^
and arms fixed to the wall, counter-extension by weight). In older people laminrr-
tomy may be done at once because the disease tends in them to progress. Sayrr^
jacket and various kinds of apparatus are used ; one of the best of these, perhaps. >
one designed by Mr. Jackson Clarke.^ In acute mydUie an ice-bag to the spine so:
the administration of atropine subcutaneously and locally have been advocated
though but little can be done beyond rest and Uie prevention of bedsores. F^r
chronic meningitis (pachymeningitis) and the six upper neuron scleroses (see §{ 556 1
560), the iodides or atropine may be tried, but counter-irritation is the best. Tli^
treatment of hysterical paraplegia is given elsewhere, but the value of faradic aad
static electricity is undoubted.

(6) To prevent complications should be our endeavour in all cases. A cathttfT
carefully asepticised should be passed three or four times in the twenty-foar hours r
cases of partial or total retention, and with considerable care, for the parts are oiuz
ansssthetic The patient should be placed upon a water bed, the bowels kept seotiT

^ See discussion Clin. Soc, the Lancet, March, 1900.

if W7, MS ] BRAOHIPLEQIA^MONOPLEQIA 803

acting wiih Uzatiyes or enemata ; aad the formation of bedsores prevented by clean-
liness, dryness, and the relief of pressure at all prominent points. The question of
nursing is of the highest importance in all of these cases, especially in cases of myelitis,
(c) The restoration of the function of the muscles may be promoted in due course
by the application of galvanism, faradism (particularly the combined current),
ma^ge, and passive movements. These means are more useful in flaccid paraplegias,
and are not suitable in recent or irritable cases or in the earlier stages of acute myelitis.
Nervine tonics, strychnine, phosphorus, arsenic, cod-liver oil, iron, quinine, are all
of value to promote nutrition. Bearing in mind the view of modem pathologiats,
that in cases of sclerosis of the cord the primary lesion is a malnutrition ol the nerve
cells and fibres, rest and a liberal dietary, especially one containing abundance of cream
and fats, should be of use, and in actual practice I have lotrnd it so.

The patient comj)lain8 o/weahneas or paralsnris of bote, arms. The case
is one of BaAOHiPLEaiA (i.e., Brachial Diplegia).

§ 587* Braehiplegia is paralysis of both arms without paralysb of the
legs. It is not a very common condition, and must not be confused with
diplegia, which is double hemiplegia, nor with brachial monoplegia. It
is met with occasionally in the following diseases. In the Diagnosis of
the cause you shoidd first ascertain whether you have to do with a lotoer
neuron lesion such as I., II., III. ; or upper neuron lesion as in VI. and VII.

L Double muaculo-spiral parcUysis (p. 805) is the commonest cause of brachiplegia,
as met with in lead poisoning and sometimes other toxic conditions, such as poisoning
by arsenic or silver.

n. In syringomyelia (§ 607) wasting and weakness of one or both arms may be the
earliestieature. The paralysis is usually flaccid, but may be rigid, and is accompanied
by loss of temperature sense and other sensory changes.

III. In a few cases of <tevte anterior poliomykUis (§ 601) both arms may be paralysed
at the same time.

IV. In certain cases of idiopathic muscular atrophy (primitive myopathy), weakness
of the muscles of the arms and shoulder girdle may be the earliest, and for a long time
the only, symptom.

y. Injury to the cord in the cervical region may result in atrophic paralysis of the
arms.

VI. In hypertrophic cervical meningitis and in extra-meduUary tumour in the region
of the cervical enlargement there is acute pain in the arms, and the " claw hand "
usually develops.

VII. Amyotrophic lateral ideroiis (Charcot) is a rare disease, due to disease of the
anterior horns and also of the lateral colunms. In the first stage, lasting usually from
four to twelve months, the symptoms are mostly confined to the upper extremities,
which are feeble, and gradually undergo atrophy, Ck>mbined with this is rigidity and
increase of the deep reflexes of the arms, which gradually assume a characteristic
position owing to the contracture of the muscles. Both arms are usually involved,
but not infrequently one side predominates. In the second stage the lower extremities
become invaded by the symptoms already described under Primary Lateral Sclerosis.
The disease differs from progressive muscular atrophy, of which some regard it as
a variety, in the presence of the stiffness both of the arms and of the legs, and also
in its relatively rapid course, for death generally takes place in from one to three years.
It more closely resembles cervical pachymeningitis, excepting in the absence of pain.

The patient complains of weakness or paralysis in one abm or one leg.
The case is one of Monoplegia.

§ 568. Monoplegia is loss of power in one limb. Monoplegia brachialis
is paralysis of one arm ; monoplegia cruralis, of one leg. Its causes are
as follows :

804 THE NERVOUS SYSTEM (|l

a. Single Nerve and Plexus Paralydis (§ 669).

I. Single nerve psialysis.
II. Plexus paralysis.

III. Occupation neuroses

IV. Arthritic atrophy.

b. Spinal Monojiegias (§ 571).

I. Acute anterior poliomyelitis.
II. Chronic anterior poliomyelitis.

III. Spinal tumours. Pott's disease, and other causes of parapl^ia (occaskiuUjl.

IV. Syringomyelia.

V. Amyotrophic lateral sclerosis, cervical pachymeningitis and other cuKf «
hrachiplegia (occasionally).

c. Oertjbral MonopUgias (§ 672).

I. Focal cortical lesions.
II. Hysterical monoplegia.

d. Certain Primitive Myopathies (§ 603).

The chief points to ikybstioatb are, first, precisely which of the muscles is aStctK
and the character of the paralysis ; secondly, the electrical reaction ; thinDj, i>
sensation of the affected part ; and fourthly, the presence of any cause at praR^
existing along the course of the nerve trunks, plexuses, or roots. It is often diffni^
to decide whether an alleged weakness in the forearm is not in reality due to dinv
in one of the smaller joints. In any case the joints should be examined, because era
after slight injury an arthritic amyotrophy (see below) occasionally ensues, which b»j
cause weakness in the limb.

Monoplegia may be due to a lesion situated (a) in the peripheral nervea, jfiexoao^'^
roots ; (6) spinal affections involving the anterior horns or anterior roots ; or vm
rarely (c) localised cerebral lesions ; the first two being paralysis of the lower neoroc
the tiiird those of the upper neuron type.

§569. Single Nerve Paralysis. — ^Peripheral nerve and nerve-pto
lesions give rise to a monoplegia which, like all lower motor neuron lesiooi
is flaccid, accompanied by R, Z)., and is followed by atrophy of the affectoi
muscles. The key to the detection of the nerve involved consists in the
identification of the precise muscles affected. The lesion may be an injuiy.
pressure, or inflammation, but the symptoms are much the same in kini
though they differ somewhat in degree. A divided nerve may be takes
as the type.

Symptoms, — ^Division of a motor nerve (or its severe contusion or com-
pression) gives rise at once to (1) flaccid paralysis of the muscles supplied
and alterations in the electrical reactions; (2) abolition of the taidoc
reflejces in the muscular region involved, followed in the course of iht
ensuing week by (3) muscular atrophy ; and (4) total loss of contractibtr
to faradism. Most nerves are mixed, and pain and various kinds of pa^
aesthesia are very constant ; indeed, pain is the most prominent symptom
in acute inflammation or severe injury. AnsBsthesia is much less constant
Sensation may remain intact, even after complete section, owing, it m
said, to the extensive overlapping of the nerve areas. Sensation, when
lost, is sooner recovered than motion. Persistent and extensive annsthesis
indicates destruction or section of more than one nerve-trunk or of a iHiok
plexus. Vaso-motor and trophic disorders often residt — redness, h7pe^

§ (MM ] SINGLE NERVE PARALYSia 805

idrosis, oedema, wasting of the skin (glossy skin), suboutaneous tissae and
bones, and vesicles followed by badly healing sores.^

The Diagnosis may always be accomplished by the electrical reaction
of degeneration. Thus we are enabled to distinguish a nerve injury
from (1) a direct muscular injury ; (2) arthritic amyotrophy following
a slight contusion of the joint ; and (3) spinal monoplegias which are
distinguished by the different course they run, and the associated symp-
toms (§ 571).

The Prognosis depends to some extent upon the degree and cause of
the injury on compression. Complete R. D. indicates complete severance
or destruction of a nerve. But it is wonderful how a nerve will repair
with rest, as Mr. John Hilton ^ pointed out long ago.

The Causes of peripheral nerve and plexus lesions are manifold, but may
be grouped under two headings, as exemplified mainly in the musculo-
spiral nerve. The special causes affecting the several nerves will be con-
sidered afterwards.

(o) Injury or Pressure. — ^Pressure during sleep (especially after alcoholic
intoxication), ligatures, the use of crutches (crutch-palsy of the musculo-
spiral), luxation of the humerus or other bones, bullet wounds, stabs,
and direct blows on a nerve or nerve-trunk (e.g.y brachial plexus above
the clavicle), or fractures, may injure the nerve ; later, callus (recognised
as a cause by the pain coming on some time after the injury) may involve
or compress a nerve, or the nerve may be included in a cicatrix (internal
or superficial). Sudden extension of the arm upwards may lead to severe
damage or laceration of the brachial plexus ; damage during parturition
may act on these or other nerves and severe muscular action (e.g., contrac-
tion of the triceps on the musculo-spiral) may act (as Sir William Gowers
has shown) by compression. Diseases of the bones beside a nerve, or
through which a nerve passes (e.^., caries or sjrphilitic disease), or enlarged
glands or other tmnours may lead to compression, and extensive pleurisy
at one apex may have the same effect. A small injury of the thumb may
lead to ascending neuritis (Eausch, quoted by Oppenheim).^ Forced
functioning leads to occupation neurosis, which may result in spasm (^.t;.),
paralysis, or tremor.

(/3) A Toxic Agent (as already mentioned in Multiple Neuritis) some-
times acts as a predisposing factor, sometimes as the sole cause ; and
the toxic agent often seems to have an unexplained proclivity for certain
nerves, as in the case of lead for the musculo-spiral. Alcohol generally
produces multiple neuritis, but may act as a contributory factor to slight
injury or local compression. Arsenic, and occasionally mercury and silver,
have been known to produce musculo-spiral paralysis. Diphtheria and
influenza are well-known toxic causes of neuritis, and the other infec-
tious fevers act occasionally. Diabetes and enteric fever have been

^ See a caee reported by the anthor in BrcMn, part IziiL, 1893.

' Hilton's " Rest and Pain." edited by Jaoobsbn ; London, Bell and Sons, 1887.

^ '* Diseases of the Nervous System.*' Lippinoott, London, 1004.

THE SEBV0V8 SYSTEM

Flf. 1G7. — Appnnliiuito txtm ol CuTunMDB SmsATion rappUed br Uib paipbirml b

¥1b. Its. — Appfoilnute ueu of CDTAKBom SinsinoM mppUxl by the perlpbersi a

HINOLB NBBVS PARALTSIS

etnUal pltxui-
cirvmrtfltx -■

ntuaaUo-attfarMOit'

ienaato Humtral

Fig. 1 SB.— Approximate Bteu of cmixwnra Sminon nippIM b; tba peitpliBMl ne

—ctrvleal pttxia.

intemoste/iuiaerai---

ntrvt ofWHaberg--

Pll. ISO. — Approximate ireu of Cutahkoits Sihbation mppKed b]' the perlpbnal ne

808 THE NERVOUS SYSTEM [ f

accompanied by paralysis of the circumflex nerve. Paralysis of the
musculo-spiral has been observed in enteric fever, articular rhemnatasm,
and pregnancy; and rheumatism and gout are believed to operate
similarly.

In the TrecUment of injury or compression of a mixed nerve the first
thing is to ascertain and remove the cause. Iodide may be given if peri-
ostitis is suspected, or operation performed for bone disease. Rest, as just
mentioned, is of paramount importance. Weak galvanism (6 to 8 m^)
regularly applied, especially in the form of a limb batii, is of tiie greatest
value, and later this may be combined with faradism and massage. If at
the end of many months' perseverance the R. D. is still present, surg^
may be summoned to our aid. Surgical treatment followed by Hie above
will sometimes completely restore muscles that have been paralysed and
with the B. D. for many years. The distal end of an injured or diseased
nerve has been successfully spliced on to anotiier healthy nerve (Purvei
Stewart and Ballance, Wilfred Harris,^ Low and others). The treatanait
of single nerve lesions is also referred to under Peripheral Neuritis (§ 561)
and Neuralgia (§ 604).

The Symptoms and Causbs of Paralysis of Ihdividual Nbrvbs will now be con-
sidered. For sensory symptoms, see Figs. 157 to 160.

The musctdO'gpiral nerre is paralysed more frequently than any other nerre of the
extremities, owing, perhaps, to its peculiar course and superficial position, and it maj
be described in detail as a type of localised nerre paralysis. It may be involTed m
paralysis of the brachial plexus {vide infra). The Symptoms are wrist-drop, due to
paralysis of the extensors of the wrist and of the fingers, together with the sapinator
longus and brevis. Sensation is affected only in a few severe cases. The oommoiiest
Cause is pressure or injury of some kind (group a). Lead poisoning is also a Twy
common cause of paralysis limited to the musculo-spiral nerve ; the supinator longis.
however, being generally exempt.

The OTHBR msBVES are less frequently involved singly. The symptoms are gfrcn
in a table below. The principal causes are as follows :

Circumflex. — Injury to shoulder, pressure, tpxic (diabetes, lead).

Long Thoracic. — Over-exertion, lifting heavy weights, injury, etc.

Median. — Traumatism, occupation neuroses (dentists, joiners* cigar-makeis, etc).

Ulnar. — Pressure and trauma, acute infectious fevers, syphilis, occupation neoroees.
Injury or disease of the lowest part of the cervical enlargement may involve only
the fibres going to the ulnar nerve ; this should be remembered before diagnoaiiig
a case as ulnar paralysis. Numbness and anassthesia in this area occur in tabes
dorsal is.

Anterior Crural. — Pressure by pelvic or vertebral tumours ; toxic (gout, alcohol
diabetes) ; femoral aneurysm.

OrecU Sciatic. — Pelvic tumours and inflammation, injury to femur, compreesioa
during parturition, toxic (gonorrhoea, gout, rheumatism, fevers, nephritis). Preeaure
within the pelvis often involves only the peroneal fibres. An habitually loaded leetitm
may cause paresis of the muscles of, and pain in, the left leg, but it should be remem-
bered that when sciatica is attended wiUi atrophy, cancer of the sigmoid flexure, or
rectum, or some other pelvic tumour should be considered.

Phrenic Nerve. — Diphtheria, injury or disease of the third and fourth cerviGal
roots. The symptoms of paralysis of the phrenic nerve are (1) dyspnoea on exexikm ;
(2) during deep inspiration the abdomen does not protrude, owing to paralysis of the
diaphragm.

^ Report of the C^n. 8oo. Lond., the Lancet, October, 1904.

§569]

SINGLE NERVE PARALYSIS

809

Table of AcrnoNs of Muscles and their Nerve Supply.

Nerve.

Posterior thoracic or
external respira-
tory nerve of Bell.

Mutdee Supplied*

SerratuB maffnns.

Snpra-tcapular.

External anterior
thoracic.

Internal anterior tho-
racic.

Hoscalo-cntaneoas.

Snpra- and Intra-tpi-
natns.

Pectoralis major
(upper part)

Pectoralis major and
Pectoralis minor.

Ck>raco-brachialis.
Biceps.
Brachialis anticns.

Subscapular.

Circumflex.

Musculo-spiral.

Snbscapnlarls.
Teres inajor.
LatissimuB dorsi.

Deltoid.
Teres minor.

Defective Movement.

Posterior interosseous
branch.

Triceps.
Anconeus.
Supinator longus.
Extensor carpi radi-

alls longior.
Brachialis antlcus.

All the supinators
and extensors of
carpus and An-
gers except supi-
nator longus and
extensor carpi ra-
dialis longior.

Arm cannot he raised
above a horizontal
position.

Disturbance in fane*
tion not pro-
nounced, paralysis
of infra-spinatns
produces difflonlty
in writing ; ot supra-
spinatus, fatigue
in lifting arm.

No movement en-
tirely prevented,
but adduction of
arm imperfectly
performed.

Forearm flexed with
difficulty, especi-
ally in snpinated
position.

In paralysis of latit-
simus dorsi forcible
backward depres-
sion of raised arm
is lost.
In paralsrsis of teres
major elevation of
shoulder with the
arm against side
is lost

Arm cannot be ab-
ducted nor ele-
vated backward or
forward.

Elbow, wrist, and
basal phalanges of
fingers cannot be
extended; grip
weakened; im-
paired flexion of
forearm If supinator
longus is involved.

Deformity Produced,

Scapula higher than
normaL On at-
tempting to stretch
arm forward scap-
ula lifts itself with
its inner border
"wing-like*' from
the thorax.

Scapular spine no-
minent when infra-
spinatus atrophied.

Characteristic de-
pression on outer
surface of upper
arm between in-
sertion of deltoid
and origin of supi-
nator longus.

Change in the shape
of the shoulder ;
relaxation of
shoulder-joint de-
velops later.

«i

Wtlst-drop," fln-
gers flexed in meta-
carpo - phalangeal
joints; thumb op-
posed to fingers
and somewhat de-
pressed downwards.

Supinator longus par-
alsrsis detected by
placing forearm
midway between
pronation and su-
pination, when
flexion against re-
sistance does not
bring musoie belly
into view.

810

THE NERV0U8 aYSTSM

III

Table of Actions op Husolbs and their Nerve Supply

— continued.

Ntfve,

Median.

Ulnar.

Intercoatala.

Lnmbar.

Anterior ororal.

Obturator.

MuteLu Supplied.

Pronator radii teres.
Palmaris longoa.
Flexor carpi radiaUs.
Flexor rablimis digi-

tonun.
Flexor longoa poUiois.
Opponent poUiois.
Abdnotor poUida.
First and eeoond

lumbricalea.
Parta of flexor brevis

poUioia and flexor

profundus dlgi-

tonun.

Flexor carpi nlnaris.
Adductor poUids.
Mnscles of ball of

little finger.
Interoesei.

Laat two Inmbrlcales.
Part of flexor brevis

poUids and flexor

profnndns digit-

onun.

i>«/MMM If ovemsftf. 2>0/onn#y Pnimd

Interoostals.
Rectus abdominis.
External obttaoe.
Internal oblique.
Transversalis.

Erector spinn.
Quadratus lumbo
rum.

Sartorlus.
Pectlneua.
Quadratus femoris.

Qradlis.

Obturator extemus.
Adductor longus.
Adductor brerls.
Adductor magnus.

Flexion of hand with
sli^t force and
with ulnar deyia-
tion. Fingers can-
not be properly
flexed at flist pha-
langeal Joint, while
flexion of terminal
phalanges only
practicable in laat
three fingers. Pro-
nation of arm lost.
Opposition and
flexion of terminal
phalanx of thumb
lost.

Patient can flex
hand, but only
with adduction t<^
wards radius. In-
ability to flex ter-
minal phalanges fA
laat three fingers
and to adduct
thumb. Basal pha-
langes cannot be
satisfactorily flexed
nor middle and
dtotal phalanges ex-
tended. Abduction
and adduction of
fingers impossible.

In paralysis of ab-
dominal muscles
forced expiration
interfered with;
only possible to
rise from a redin-
Ing position by
ji^ng arm as a
support.

The back in walking
and standing
thrown backward;
on sitting spinal
column is ardied
convexly back-
ward.

Inability to extend
lower leg. Absence
of knee refiex. Pa-
ralysis of ilio-
psoas CTidenced by
inability to flex hip.

Adduction and to a
slight extent exter-
nal and internal
rotation impaired.

Pooitton of hand Mt

tirficd

utaia ad
hold slightly mi-
DAted. WMttagof
thenar mofclM
conspiouoas.

"ClJiw hand." not
pronounced ii

fourth and ifth
llngen. JJaift^r
lanx in extnv
extenaioa soad mo-
end and third biU
firmly flexed;
atroi^ of hypo-
thokar emiaeiet
and of intsrosMi

Lordosis: peiri*
strongly beat tor
ward ; abdoati
and nates show IP
promineotly.

aiii^t lordosii wbi«h
disappeafs on jy
dining; ?•!▼»»
raised.

Gait disturbed. ^
tientstepptallf^
fully, aroldiBi
flexion of kase.

{570]

PLEXUS PARALYSIS

811

Table of Actions op Musoles and their Nerve Supply

— contintied.

Nertfe.

MiueUi Supplisd.
Olntens mazimni.

I>f/MfJM If O«0m«fl<.

D9form4tv Prod¥Cii.

Inferior gluteal.

Abdnotion and par-

In walking, leg

tionlarly extension

swings too far In-

at hip Joint ham-

wards, also exces-

pered.

sive lifting and
sinking of pelvis-
waddling gait.

Saperior gluteal.

Qlntena medius.

Loss of abdnotion

Glntena minimni.

Tensor vagine fe-

tion of thigh.

moiii.

Internal popliteal.

Gattvoenemini.

Loss of plantar

Claw position of toe

Solena.

flexion of foot and

(pied en grilTe), pes

Tibialia poatioaa.

toea.

calcaneus or val-

Flexor oomnranla dl-

Patient unable to

gus.

lift hhnself upon

Flexor longna hal-

tips of his toes.

Inola.

Walking diffionlt.

External popliteal.

TiblaUs antiona.

Foot falls from its

•• Foot-drop." Foot
remains in eqnino-

Kxtinnnor proprlns

own weight, and

haUnda.

oannot be raised.

varos position.

Extensor longus dig!-

nor can first pha-

tomin.

lanx be extended.

Peronel.

Walking difllonlt.

Extensor brevis digi-

toes scrape the

tonun.

floor.

f ff70« n. Plezns Panljiif» paralysis dne to a lesion involving a nerve plexus, is
another oanse of monoplegia. It is recognised by the number and extent of the mnscles
involved. It is not always possible to distingoish nerve root from nerve trunk
involvement.

L There are three forms of brachial plexus paralysis :

(1) Upper brachial plexus paralyeie €i the shoulder and arm (Duchenne-Erb)

i nvolvee Uie muscles of the upper arm — namely, deltoid, biceps, brachialis anticus

and supinators* sometimes inf la-spinatus and sub-scapularis. It results from tumours

or leeions involving the fifth and sixth cervical roots, or by injuries pressing the clavicle

against the first rib or spinal column.^

(2) Latoer braehial plexus paralysis of the forearm is much rarer. It involves the
musoles of the hand and the flexors of the forearm, sensation being impaired in the
region of the ulnar nerve, the inner surface of forearm and upper arm.

(3) Total hraehial plexus paralysis is very rare, and always traumatic.

Brachial neuritis, a toxic, ill-defined affection of several of the nerves of the arm,
or ol the whole of the brachial plexus» is described under Pain ({ 004), which is its
leading symptom.

Obiielrieal paralysiSt due to injury during parturition, very often takes the form
of upper brachial plexus paralysis; sometimes the facial nerve is injured by the
forceps. Recovery generally takes place in course of time. Other forms of birth
palsies are referred to under Hemiplegia.

IL Lumbar and saoral plexus paralysis is much rarer than brachial, and is due to
tumours or disease adjaoent to the lumbar or sacral vertebrae. The sigmoid flexure
Is a frequent primary seat of malignant disease, and may make itself manifest by
sacral or sciatic paralysis. The anterior crural nerve (see table) is generally
involTed.

^ It was this paralysis that Harris and Low successfully treated by cross union of
the nerve roots {Brik Med, Joum,, October 24, 1903).

812 THE NERVOUS SYSTEM [ 0 *714»

HI. Oconpatton neuroiM, such as writer's oramp, telegraphist's palay, etc. may h
attended by paresis, but they more often oonsist of a musole spasm, under wliiek th^
are desoribed ({ 584).

IV. Arthritio amyotrophy is described under Amyotroi^iy ({ 603). It is dm to
wasting of some of the extensor muscles following contusion or disease of the jciat
sometimes of quite a trivial kind.

§ 671. Spinal Monoplegias. — ^AfEections of the spinal coid may give ib?
to monoplegia .when the lesion involves the anterior horns or anterior roots.
We are therefore in presence of a latoer motor neuron paralysis, which di&n
from the last group only in the circumstances under which the paralvsk
occurs, and in the distribution of the muscles involved.

I. Aente Anterior Poliomyeliiis (Infantile Paralysis) is described under
Muscular Atrophy (§ 601). It is the commonest cause of monoplegia in
childhood, and though it may aSect more tluui one limb at the oata^
55 per cent, of all cases settle down into a crural monopl^ia. In 23 per
cent, of the cases one arm is affected.

n. Chronic Anterior Poliomyelitif (Progiessiye Muscular Atrophy) is met witfc
chiefly in adults as a slow progressive amyotrophy starting at the ei^ <^ the limls.
generally in the hands, sometimes in one hand.

in. Spinal Tnmonn, or Pott'i Disease, especially when pressing on the nerre rooti.
in the region of the brachial or lumbar plexus, may conunence with monoplegia, and
are recognised by lancinating pains shooting from the back down the limb» tiie gndi»l
advent and prolonged course of the paralysis, and the concomitant symptoms dor
to pressure upon the cord (§ 557).

rV. Syringomyelia frequently starts as an atrophic paralysis of one, sometimeB d
both arms, associated with various sensory and trophic symptoms (§ 607).

V. Amyotrophic Lateral Sclerodi and Oervieal Pachymeningitis commeoce as as
atrophic paralysis of one or both hands. They are relatively rare diseases.

S 672. Oarebral Monoplegia. — Cerebral lesions generally produce hemipleigia ; only
very rarely a monoplegia. The clinical features here are those of an upper motor
neuron lesion, which would at once distinguish it from the two preceding groups.

L Focal cortical lasioni producing monoplegias are comparatively rare. Kmboliwi
or thrombosis of the anterior cerebral artery (not a common position) produces a enusl
monoplegia. Occasionally vascular lesions in he aged involve the arm and faee
centres only. Tumours limited to one of these centres are practically unknown.^

II. Hysterical monoplegia (arm or leg) is less rare than organic cerebral monoplegia.
Hysterical monoplegia generally dates from an accident or nerve storm or attack of
some Idnd, and it is usually attended by segmental anesthesia — i.e., the area of kss
of sensation is bounded by a circular line drawn round the limb, usually at a joint.*

The fotient complains of a widespread paralysis or muscular weakness.
The case is one of Genbralised Paralysis (general debility being ex-
cluded).

§ff78. Oeneralised Paralysis is met with towards the end of quite a
number of nervous diseases, but only a few begin with an involvement of
all the limbs. We must be careful to exclude the causes of general debility
(Chapter XVI.). General paralysis accompanied by stifEness is described
under Spasm (§ 582).

^ One cause has been recorded by Professor J. M. Charcot and one case by Dr. A.
Hughes Bennett.

^ A very typical case forms the subject of a clinical lecture by the author in the
Clinical Journal, May, 1904.

§671] GENERALISED PARALYSIS 813

i: Toxic or Funeiional.

Multiple peripheral neuritis due to alcoholism, diphtheria, syphilis, etc
Hysteria.
* Paialysis agitans.

Myasthenia gravis.
Family periodic paralysis.

, Intracranial Lesions.

General paralysis of the insane.
Diffuse basal tumours.
Oerebellar tumours.
Cerebral pachymeningitis.
Infantile diplegia oerebralis.
Encephalitis.

Spina?, and BtUbo-Spinal Lesions.

Disease or injury high up in the spinal cord.

Cervical pachymeningitis

Disseminated sclerosis and other chronic degenerative conditions.

Bulbar paralysis.

Landry's paralysis.

Diffuse myelltb.

Acute anterior poliomyelitis.

Progressive siHnal muscular atrophy of infante.

Amyotrophy.

Idiopathic muscular atrophy.
Amyotonia congenita.

In seeking to diaonosb thb oausb of a case of generalised paralysis of this kind one
naturally turns fir^ to some possible toxamic or fundional condition such as alcoholism
and hysteria.

Secondly^ the possibility of some intracranial disease, such as a basal cerebral or
cerebellar tumour, or general paralysis of the insane would next engage our attention,
and we should seek for the associated symptoms referable to the cranial nerves or to
the mind.

Thirdly, we might suspect some spinal or hvlbo-spinal disease when the peripheral
s3rmptoms, or symptoms referable to the cranial nerves, would be more prominent
than the cerebral or mental symptoms.

Among the Toxio and Functional causes, ehronic alcoholism is not
infrequently followed by a general weakness passing on to a generalised
paralysis. It is probably due to peripheral neuritis or a generalised toxic
degeneration of the nervous system.

Other causes of peripheral neuritis, such as diphtheria,^ may also pro-
duce general paralysis. The syphilitic toxin may produce peripheral
neuritis, but it more often produces General Paralysis of tiie Insane.

In the last stages of hydrophobia general paralysis ensues.

In Hyit«ria I have occasionally met with a flaccid paralysis coming on suddenly
and affecting all the limbs.

Paralyiii Ayit^w ({ 590) is from the outset attended by weakness of all the limbs.
This gradually increases until the patient becomes bedridden, and all the limbs become
stiff and powerless.

§ 674. Myatlheiiia GrtTis (Asthenic Bulbar Paralysis) is a rare condition, possibly
toxio in origin, consisting of progressive weakness of all the cerebro-spinal muscles.

^ Dr. F. E. Batten (BriL Med. Joum., November 19, 1898) has shown that very
few of the nerves really escape in diphtheritic paralysis.

814 THB NERV0V8 SYSTEM [ i fTl

It was first described by Willis in " The London Practice of Physic " in 1866, and
studied again by Sir Samuel Wilks in 1877. and Erb in 1878. About sizty cases had
been recorded up to 1900.^

Symptoms, — 1. The patient easily becomes tired, and the muscular weaknew ii
always worse in the evening. All the voluntary muscles of the body are affected, but
especially those of the face, eyes, and neck. Bilateral ptosis is present in abont
80 per cent, of tho cases, and all the ocular muscles are weak (ophthalmoplegia eztema).
The face is expressionless, and there is often a difficulty of swallowing and of aitaoul%>
tion. A nasal speech after talking awhile and a difficulty of mastication after starting
to eat are other examples of the rapid fatigue of the muscles. Paroxysmal dyspnoea
may supervene. All the symptoms vary in intensity from time to time, bat the
patient gets gradually weaker. 2. The reaction to faradism is characteristic, for the
muscles become exhausted in a very short time. Although the musoles will oontzaet
at the moment when the terminal is first applied, they soon become completely fiaecid
again, and after several applications may fail altogether to respond. This, the myas-
thenic reaction, is quite peculiar to the disease. 3. There is no fibrillation, no obvioos
muscular atrophy (till late in the disease), no reaction of degeneration, and no aensoij
changes.

Diagnosis, — CSases may be mistaken for bulbar paralysis, in which, however, the
ocular symptoms are wanting. Diphtheritic paralysis is like myasthenia, bat the
myasthenic reaction is wanting ; so also in neurasthenia, hysteria, and the early phases
of chronic degenerative lesions. In Addison's disease there are pigmentation, emacia-
tion, and other symptoms.

The Prognosis is grave, the disease is insidious, and may last for several years, bat
io the end is fatal, either from asphyxia or some intercurrent affection.

The Etiology is uncertain. Young persons are mostly affected. The generalised
character of the symptoms and the resemblance of myasthenia to diphtheritic paralysb
suggest a toxic origin. The thymus is often found to be persistent and enlarged, and
small masses of lymphoid tissue may be found in the musdes. Dr. Farquhar Boziard
has described minute lymphorrhages in the muscular tissue as a constant and charac-
teristic lesion.

For the Treatment rest, massage, full doses of strychnine, iodide of potassium and
mercury may be tried.

Family Periodic Paralyiis is a rare disease characterised by attacks of paralysb
of gradual onset after exertion. The attacks last six to sixty hours, and daring
this time there is motor flaccid paralysis of limbs and trunk. There is no response to
galvanism or faradism. Treatment with diuretics and alkaline drinks eliminates the
toxin, and recovery is gradual.

Intracranial Lesions mostly produce hemiplegia, but there are three
conditions which may produce generalised paralysis.

General Paralysis of the Insane (§ 541), which is a chronic degenerative
change in the cerebral cortex, gradually passes on to a generalised paralysis.

Diffuse basal tamonn or gummatous meningitis involving the pons or the peduncles
may cause generalised paralysis, but in that case the cranial nerves are also
involved.

Oerebellar tnmoiiri may produce general paralysis, associated with nystagmus and
a characterised gait (§ 577).

Cerebral pachymeningitis produces a vague generalised paresis and mental weakness.

HsBmorrhage or injury at birth may cause paralysis of both arms and legs (infantile
spastic diplegia).

§ 675. Encephalitis (Polio-encephalitis) is a morbid condition to which attentioo
has been directed by Dr. F. E. Batten and others (Dr. F. £. Batten. " Acute
Folio-myelitis and Encephalitis/* the Lancet, December 20, 1902 ; and ** Polio-
encephalitis Inferior/' Trans. Path. Soc., London, vol. liv., part iii., 1903), in which
miliary foci of thrombosis affect the cortical colls in the same way as anterior polio-
myelitis affects the anterior horns. The subjects are mostiy children. The symptoms

^ Dr. Harry Campbell and Dr. Edwin Bramwell, Brain, 1901.

H 57e, 577 ] LANDB TS PAHAL 7818— ALTERED QAIT 815

necessarily difier with the position of the miBchief , but a generalised weakness is not
uncommon, and this may be associated with symptoms of insular sclerosis or ataxy.
I have occasionally seen what appears to be a diffuse inflammation of the brain sub-
stance (encephalitis). I remember a case of recent syphilis in a man of about thirty-
one, who was admitted into the infirmary with sjrmptoms of cerebral irritation — rest-
lessness, muttering delirium, general weakness and commencing optic neuritis, who
died a few days later comatose. After death the organs of the body and the meninges
were healthy, excepting for congestion, but the brain was deeply injected, and its
whole substance extremely soft, so that it could be washed away under the tap, and
was of a brownish tint. Under the microscope the cortical cells were swollen, blurred,
and granular. The cerebral arteries appeared to be quite healthy.

Among SPINAL and bulbo -spinal lbsions Foil's disease and spinal tumonzs high
up in the cord may involve all four limbs, the mind remaining clear. Injury at birth
affecting the upper part of the cord causes infantile spastic paralysis (§ 660, xii.)»
though it is more usually a paraplegia only.

Cervioal pachymeningitis, amyotrophic lateral sclerosis, and progressive muscular
atrophy may produce a like effect.

Disseminated sclerosis, tabes, and other degenerative spinal lesions may terminate
in generalised paral3rsis.

Bulbar paralysis (glosso-labio-laryngeal palsy) may affect all the limbs when it comes
on acutely. Chrcmic cases are only affected by generalised paralysis in their final
stages.

§ 676. Landry's Paralysis is a rare condition of ascending flaccid paralysis, of which
the pathological explanation is obscure.

The 8ympkmi8 start with flaccid paralysis of the legs, rapidly extending to the trunk,
arras, and neck, and cranial nerves in some cases. It usuaUy terminates fatally from
involvement of the respiratory muscles, in two days to two weeks. There are no (or
very slight) sensory changes, no muscular atrophy, no trophic or electrical changes,
and no loss of sphincter control. The spleen has been enlarged in some cases.

Etiology, — It occurs chiefly in males between twenty and thirty. It bears consider-
able resemblance to a rapid peripheral neuritis, and it has been suggested that it is
due to an acute toxemia of the lower motor neuron. A tetracoccus has been found in
the spinal fluid by lumbar puncture (Farquhar Buzzard).

Acnte diffuse myelitis may rapidly ascend the spinal cord, and cause an acute
generalised paralysis. There is anaesthesia and loss of sphincter control, but no
muscular atrophy (§ 669).

What used to be called acute spinal paralysis of adults is really an acnte anterior
poliomyelitis similar to that affecting children (§ 601). Wasting is rapid, with B. D.,
and recovery is never complete. A subacute form is also described.

General paralysis associated with extreme wasting of the muscles is seen in the later
stages of the idiopathic muscular atrophies, and the peroneal type of myopathy (§ 603).
The gradual onset in youth, the progressive course of the disease, and the hereditary
history aid the diagnosis.

/3. Inco-ordination and Disordered Gait.

§ 577* Tho Gait of all patients suffering from motor defect should bo
carefully studied ; it will often teach us a great deal about the malady.
The defect may be due to muscular weakness, to muscular rigidity, to
clonic spasm, to true inco-ordination, or to want of balancing power. The
most characteristic disorder of the walk occurs in the inco-ordination of
tabes dorsalis and the sinuous or reeling gait due to want of balancing
power in cerebellar lesions. The anatomical remarks on this subject
(§ 503) may help to explain what follows.

816 THE NERVOUS SYSTEM [ { 99%

The various diseases in whioh disordered gait is met with may be grouped as follows:

a. Inoo-obdhiation (or ataxy) is met with most oharacteristicaUy in (1) locomakr
ataxy (tabes dorsalis), in whioh there is an exaggerated movement, a stamping gait,
with the feet wide apart, lifted high, and brought down forcibly — ».e.. the patient bemg
unable to oo-ordinate his movements. It is met with in other diseases a£Eeotuig iLt
posterior columns — ^namely (2) epinal twmour a£Eeoting the posterior columns, especially
in the lumbar region ; (3) chronic posterior epinal pachymeningitis ; (4) Friedrtkk*4
hereditary ataxy (rare) ; (5) ataxic paraplegia (rare) ; and (6) other conditioiis where
the posterior columns are involved primarily or secondarily.

6. Beslino Gait, or swaying like a drunken man, is met with most typically in
(7) cer^)€Uar disease. It also occurs in patients who are the subjects of (8) frequent
or continuous vertigo, either from circulatory or other causes.

c The Spastic Gait is a stiff gait, owing to the stiffness and rigidity of the legs, dae
to lateral sclerosis. By degrees the patient takes to walking on tiptoe, the toes tom
in, and are scraped along ^le ground. Later still we get what is called oroaa-legged
progression owing to the predominance in the contracture of the adductor muscles.
This may occur on one or both sides. On both sides it ia met with in the various (9) rigid
or spastic parctplegias and in ataxic paraplegia. On one side it occurs in (10) oigaoie
hemiplegia, owing to descending sclerosis in which the spastic character of the gait
induces a circumduction of the rigid limb as it is brought forward in walking, whioh,
as Sir Benjamin Brodie pointed out many years ago, is in strong contrast with the flail-
like flaccidity of many functional hemiplegias. It must be remembered, however,
that this distinction oidy applies to hysterical hemiplegia when the paralysis is fl^f^^^^
Some cases are attended with rigidity, and in these the distinction does not obtain.

d, Fbstikatiok is the gait in which the patient bends forward as he walks ^Mtcr
and faster, tending to fall forward, his face looking fixedly in front of him. It is met
with in (11) paralysis agitans, and to some extent in old age.

e. In the Hioh-Stbpfino Gait the patient raises his knees too high. It is met with
typically in well-marked (12) peripheral neuritis and other amyotrophic (lower neuron)
paralyses attended by foot-drop, on account of the predominance of the paralysis in
the extensor muscles, the patient, so to speak, flinging the foot upwards instead of
raising it. It ib also met with in (13) pseudo-hypertrophic paralysis.

/. There is a peculiar " Jaunty " or dancing walk in (14) chorea, associated with
excessive arm movement, whioh is very characteristic Other tremors ({ 689) may
render the walk peculiar.

g. There is a very characteristic attitudb and gait, with the head and arms t^^gwig
forward owing to the weakness of the neck muscles, in (15) post-diphtheritic panJ^fsis
of childhood. It can be recognised as a child walks into the out-patient room.

A. The Waddlino gait is met with in (16) congenital hip dislocation, advanced
rickets, achondroplasia, all conditions of dwarfism and in coxa vara. This last named is
a peculiar congenital condition, in which the neck of the femur forms a leas obtose
angle than is usual, and causes the patient to sway from side to side as he walks.

i. The LiMPiNO Gait is met with as a result of (17) infantile paralysis and in any
(18) injury or joint affection confined to one side.

§ 578. Tabes Donalis (Locomotor Ataxy) may be defined clinically as

a very chronic disease commencing with disturbances of the muscle sense

and various other derangements of sensation and of the cranial nerves,

and terminating in total abolition of the faculty of co-ordinating the

voluntary movements; muscular power usually remaining intact until

near the end. It is essentially a sensory, sensorial and muscle-sense di»-

order, syphilitic in origin. Ten years is the average date of onset after the

syphilitic infection ; very rarely under four years.

To understand this disease, it is necessary to refer to its Histo-pathology. It is inter-
esting to notice that in the course of years our knowledge of tabes has. as it wetc,
shifted clinically backwards, so that what were formally regarded as the ecseatial
symptoms of the disease are now looked upon as complications or sequelaB. At first

S 585 ] OOOUPATION OBAMP 827

render the treatment comparatively simple, but, as a matter of fact, it is
very difficult because the malady is chiefly found in those whose daily
bread depends upon the performance of a certain muscular movement.
Careful re-education can, however, accomplish a great deal, and particu-
larly the adoption of a freer and larger style of writing, by holding the pen
fnore loosely and in a different way. The patient shovdd learn to hold the
pen between the first and second fingers with the back of the hand against
the paper, and practise writing a series of large sloping BTs. A certain
amount of rest — at any rate, at the outset — is indispensable. Mean-
time the patient should begin learning to write with his left hand«
Sedatives are of service, especially in neuralgic forms, such as chloral,
bromide, small doses of morphia, physostigma, Indian hemp, belladonna,
or atropine {j^^ grain hypodermically two or three times a week). Nervine
tonics are recommended, and even strychnine, but I have often observed
this remedy do more harm than good. Faradism also does harm, but
voltaic electricity has often seemed to me particularly beneficial, especially
when combined with massage. Gymnastic exercises are strongly advo-
cated by some. One remedy — cod-liver oil — has rendered great service,
and some of the most successful cases I have seen have been treated by a
combined method of moderating the amount and improving the style of
the writing, and the administration of small doses of bromide and cod-liver
oil. In many cases dyspepsia or a rheumatic or gouty taint is present,
which should be met by appropriate measures.

Other Oecapation Neuroses resembling the foregoing are found among
telegraphists, drapers (in using scissors), cigarette rollers, violin-players,
piano-players, t3rpewriters — any occupation, in short, which necessitates
the constant repetition of one particular movement.

Cramp is a tonic mnaoular spasm ooourring in one or more muscles of a limb. It is
a troublesome symptom of not infrequent occurrence in persons apparently in good
health. It is most apt to come on at night. A muscular cramp of great severity may
seize one or all the limbs, and even the respiratory and trunk muscles of a swimmer,
and prove very deadly unless aid is close at hand. It is apt to come on in those whose
muscles aro exhausted, but a low temperature of the water plays some part. Some
persons S(^m prone to be affected by cramp throughout life on slight causes, such
as l3dng with the limb in a strained position. Others only suffer from it when their
digestion or general health is out of order. The best remedy is to get out of bed and
gently move and rub the limb. Bromide and chloral hydrate will generally prevent
its occurrence, and any lithssmia, gouty or rheumatic tendencies should be corrected.
Cramp is a frequent premonitory symptom in peripheral neuritis and phlebitis. It is
also met with in subjects of Bright's disease and gout, and cramp of the legs is a painful
symptom in the first stage of cholera.

S 685. Tetanus is a severo disease characterised by paroxysms of tonic and some
times clonic spasms, due to the inoculation into a scratch or wound of a specific microbe
whose chief habitat is in the earth.

Symptoms. — (1) Within a few days after the injury the patient complains of stiff-
ness of the jaw and back of the neck. (2) Very soon these muscles become rigid.
The condition of the jaw is known as trismus, or lock-jaw, in which the jaws cannot
be separated. This tonic rigidity affects all the muscles of the trunk, and in a less degree
of the extremities. The back is rigid, sometimes arohed in the position of opisthotonos,
in which only the head and buttocks rest on the bed. Or there may be flexion to one
side — pleurosihotonos, or bending forward of the body — emprosthotonos. The angles of

THE NERVOUS SYSTEM

[IW

malady in its earliest phase, because at that time treatment ia more
efficacious, and the disease may ia some cases be arrested. The symp-
toms are most varied ; the one which is present in over 80 per cent, of
the cases is loss of knee-jerks. The ankle-jerk is lost even before the
knee-jerk.

(a) In the Pre-alaxic Stage the moat important and chaTact«ristie
symptoms consist of "lightning pains," vague disturbances of aeasation,
changes in the pupil, and other ocular symptoms. Any of these, combinfd
with loss of knee-jerk, is almost sufficient for a diagnosis. (1) The ** light-

ning pains " or crises, of tabes are characterised by beii^ erratic, evan-
escent, recurrent, and sometimes periodic. Tabes should be suspected ia
any neuralgias having these chaiaoters, especially in the sciatic nerve, hot
any sensory nerve may be afiected. A " girdle pain " round the waist »
another frequent symptom in the early stages — six years before any- other
symptom in a case I saw recently. Pains also occur in the situations <A
the various viscera, and come on in attacks, which the French writers have
named " crises." Thus, there may be attacks of gastric pain, followed,
perhaps, by vomiting (gastric crisis) ; or rectal pain, which may be attended

587-589 ] TREMORS AND CLONIC SPASMS 829

Tlie Treatment should be directed to the causal condition. Bromide, chloral
liydrate, and immersion in cold water (unlike Thomsen's disease) will relieve the

§ 587. Hydrophobia is a contagious disease characterised by spasms of the muscles
of deglutition and respiration, and due to inoculation by the saliva of an animal suffer-
ing from rabies.

Symptoms^ — (1) After an incubation stflkge, during which the patient presents no
symptoms, which is generally about six weeks, never less than twelve days, and may
even last as long as twelve to eighteen months or more, there is an insidious onset
of malaise, with perhaps slight fever, and sometimes tingling in the wound. (2) With
or without premonitory symptoms paroxysms of painful spasms of the pharynx super-
vene, coming on at first with a slight stifiEness, and brought on by any attempt to
swallow. (3) These spasms, at first clonic, become tonic, lasting a quarter to half an
hour at a time, and spread to the muscles of respiration and of the neck. The attacks
produce excruciating p^n and agony of mind. The mind is quite clear, but in the
intervals there are prostration and general hypersesthesia. (4) Paralysis ensues in
three or four days* time, first of the muscles of the lower jaw, and death follows within
a week from the onset.

TrecUment, — ^To destroy the virus at the seat of entrance suction immediately after
the bite is heroic, but efficacious. Cauterising the wound may be employed. The im-
munisation treatment of Pasteur is dealt with in § 386. Narcotics, chloroform inhala-
tion, and chloral may be employed.

§ 588. Thomfon's Disease (Congenital Myotonia) is a rare and obscure condition of
universal muscular stif&iess of indefinite duration, aggravated by rest. Tension and
stiffness of the limbs are experienced on first attempting to rise after resting, but they
relax to some extent after continued movement. The muscles of the lower extremities
are affected most, but those of the face, tongue, and eyes may be similarly involved.
The stiffness is increased by cold. Sometimes there appears to be slight hypertrophy,
never atrophy. The galvanic reactions vary, but faradism is never lost, and this
leads to the idea that the disease is in the muscles, not in the nerves. The malady is
noticed for the first time in youth, and is very probably congenital. Several members
of a family may be affected. The disease does not appear to shorten life. Warmth
and continued activity relax the spasm to some extent.

Arthritic rigidity is known by its being associated with some joint lesion, though
the latter may be very slight. It affects both the extensors and flexors of the
joint, though chiefly the flexors. I have usually noticed that it is increased during
sleep.

There are irregular movements or shaking of the affected mitscles, the
range of the movements being either smaU (Tremor), or large (Clonic
Spasm).

§ 589. Tremors and donic Muscular Spasms form a very frequent and
pronounced symptom in many different nerve lesions. For clinical pur-
poses abnormal muscular movements may be divided into tremors or move-
ments of small size, and clonic spasms or movements of larger range;
paralysis agitans may be regarded as a type of the tremors, chorea as a
type of the clonic spasms. The symptoms we are now considering must
not be confused with generalised convulsions or fits (§ 597), nor with the
uncertain movements of paralysed limbs or tabes dorsalis.

Classifioation, — It will be convenient to consider first the diseases in
wiuch tremors occur (such as paralysis agitans), and later the causes of
clonic spasms (such as chorea). But this division must not be taken too
absolutely for those which are commonly small are occasionally apt to be
large, and vice versa.

820 THE NERVOUS S Y8TEM [ j ITS

pays much heed to it.^ In the knee-joint, which is the favoorite aiinatioD,
the swelling is less likely to be overlooked. The occurrence of each m
arthritis, combined with the pupillary changes and absent knee-jerk, are
alone enough to establish the diagnosis. The nails may be affected vitJi
a sort of painless idceration ; the teeth may be similarly affected and drop
out ; or perforating idcers of the foot may occur. All these lesions have
the same slow chronic characters. It will be observed that the pre-ataxie
symptoms fall into two categories— central or cranial, and peripheral—
and this is now explained by the researches of Sherrington and Batten
(Fig. 161). As to their relative value, if the patient be a male, of an age
between thirty and fifty, and present symptoms taken from any two of
the above groups, I believe one is justified in diagnosing the disease.

(b) The Ataxic Stage consists of the above symptoms, which graduaUr
become emphasised in the course of years, combined with (1) the character
istic walk ; and (2) loss of equilibrium on standing. The normal power of
the muscles remains, and their nutrition is often remarkably good, but the
patient cannot control them. The typical ataxic gait has been described,
and is easily recognisable when once seen (§ 577). These patients find a
difiiculty in starting to walk, but, once started, they may improve as the?
go on, up to a certain point. They also have great difficulty in taiDisg
round, and the late Dr. Hilton Fagge mentioned an amusing incidoit of t
patient who once explained his unpunctual arrival at the hospital by Ui
having started in the wrong direction, and being compelled to con-
tinue until he met someone who could help him to turn round and stait
the other way. The arms are much less affected than the legs — at an?
rate, xmtil quite late. The patient can write or pick up a pin, but there
is often a difficulty in touching the nose when the eyes are closed. The
loss of equilibrium on attempting to stand with the eyes shut and the heds
together is known as Romberg's sign, and is very characteristic of this
disease. This is due in part to the loss of sense of position (see § 503).

(c) The Terminal Paralytic Stage is really the stage of complicatumL
and it may be many years before this stage sets in. The mind remains
clear in most cases until quite the end, and the patient may be able to
conduct his business for ten, twenty years or more after his locomotion has
become imperfect. By degrees the inco-ordination becomes extreme, and
by-and-by paraljrsis supervenes, generally, though not always, of an
atrophic form. Bladder complications are frequent, and various othei I
visceral conditions supervene ; death results from these or bedsores, not
from the disease. Perhaps the most frequent cause of death is pneumonia.
Bulbar paralysis may supervene, but one of the most frequent of the nerve
complications of tabes is general paralysis of the insane (paralytic de
mentia) ; and in visiting an asylum, it is remarkable to learn what a large

1 In an interesting case narrated by Charcot, the patient who was doing his miUterT
service, casually found that he could not march as well as the others, and on eiamm*-
tion it was ascertained that the two hips had gone on to dislocation (** Novrelk
loonographie de la Salpfitritre," tome v.).

f 678 ] TABES D0RSALI8 821

number of general paralytics have commenced as cases of tabes. Many
varieties and transitional forms are met with in these two diseases among
out-patients, and give rise to much difficulty unless you remember this
frequent association.

Causes. — (1) Age. — ^Like general paralysis of the insane, tabes is almost

entirely confined to adults between the ages of twenty-five and forty, and

(2) it is almost entirely confined to the male sex — certainly over 90 per

cent,^ (3) Syphilis can very generally be traced in the history of cases of

tabes, and in spite of the fact that iodides and mercury fail so completely

in the treatment of tabes, there is very little doubt that tabes is really a

slow parasyphilitic degeneration of the muscle-sense neurons. (4) A

history of neuropathic antecedents, and especially alcoholism in the parents,

is often present. Professor J. M. Charcot^ insisted very much on the

potency of alcoholism in the father as a cause of this and many other

nerve affections. Sometimes a family history of other nervous maladies can

be traced. (5) Prolonged bodily fatigue, especially if combined with exposure

to cold and malnutrition, acts both as a predisposing and exciting cause.

The disease is frequent in postmen, conmiercial travellers, and others who

lead an active life. This is interesting in connection with the theory of

origin in forced functioning just referred to. Among the rarer causes,

venereal excess, prolonged grief, anxiety, or mental strain may be mentioned.

The Diagnosis of tabes in typical cases — and tabes is one of the few

diseases of the nervous system which usually conforms to a type — ^is not

difficult excepting in the very earliest (pre-ataxic) stage. The age, sex,

and syphilitic history are very characteristic, and the only disease apt to

be confused with it at this time is general paralysis of the insane, which,

however, usually presents the mental peculiarities and muscular tremor

that are wanting in tabes ; compound cases occur. In the ataxic stage it

may have to be differentiated from lumbar tumour, peripheral neuritis,

pachymeningitis, ataxic paraplegia, and other diseases which will be

mentioned below. The Wassermann test is positive in the blood ; negative

in half the cases in the cerebro-spinal fluid. Lumbar puncture (§ 626) aids

in diagnosis by showing a considerable increase of lymphocytes.

The Prognosis of tabes has hitherto been regarded as hopeless — at any
rate, for cure — though the disease occasionally lasts throughout a patient's
lifetime without materially shortening it. But by degrees, by careful
attention to clinical detail, we have learned to recognise it in its earlier
stages, and much may certainly be done at that time to arrest or delay
the degenerative process. The prognosis rests chiefly on three points — ^first,
upon the rapidity of development of the symptoms; secondly, on the causes

^ The fact of tabes predominating so markedly in the male sex is interesting in con-
nection with the theory of *' forced fonotioning/* which may be briefly stated thus :
Prolonged forced fimctioning of any nerve s^cture (especially if combined with
malnutrition), results, in oonrse of time, in atrophy and overpowering of this structnre
by the surrounding tissues, and its oonseauent defeneration. Males use their oo-
ordinating and muscle-sense apparatus mucn more than females.

^ ** Ghaque goutte de liqueur s^minale d'un alcoolique contient, en germe, la famille
leuropathique tout enti^ ** (** NouvdUe Iconographie de la Salpetrike **).

822 THE NERVOUS SYSTEM [§W»

in operation, especially when some of them are removable ; and thirdly
(the most important point) the stage at which the disease is recognised.

Treatment, — (a) For the curative treatment all antisyphilitic treatment is
almost useless, though mercurial inimctions and injections may be tntd
and sometimes assist in the early stages ; iodides are certainly nseleas.
The leading principles which I have found most useful are the cessatioQ
of function of the deranged structures, a liberal dietary, combined with
galvanism. Perfect rest in bed should be enjoined, the patient not being
allowed even to stand for an instant. The dietary should contain a lar^c
proportion of fatty foods ; tonics may be administered to promote the
assimilation, especially cod-liver oil, as being, in my opinion, the remedy
which is the best " nerve food." Electricity requires great judgment, and
should not be applied to cases which are irritable or rapidly advancmg.
The best way, I have found, is to apply an ascending current to the spinal
cord, the negative pole being fixed on one side of the back of the neck,
and the positive pole being shifted from place to place down the back of
the spine on the other side, resting half to one minute at each place. The
strength of the current should be very moderate. Long sittings and
strong currents should be avoided, but a sitting should be held every d»y.
The system of exercises elaborated by Dr. Praenkel has for its object the
education of the lost power of muscular co-ordination. I have applied
this method of treatment in earlv and suitable cases with marked benefit.
The bladder should be emptied every four hours, as it is important to pre-
vent paralysis of that viscus. Belladonna and ergot may be given in cases
where congestion of the cord is suspected from the presence of spinal pain
and rapidly developing symptoms. Arsenic, silver, and other metals I
believe to be injurious ; at least, I have known patients go back ond^
their use. Patients should certainly avoid anything like fatigue of mind
or body. Sexual excess, exposure to cold, alcohol, and tobacco should be
avoided. (6) In regard to Symptomatic Treatment, the most important
symptoms calling for treatment are the lightning pains. Morphia must
be forbidden, for with a recurrent pain like this the habit is bound to be
developed. On the other hand, the same treatment which cures or modi-
fies the disease also relieves the pains. Phenacetin, antipyrine, hyoscya-
mus, belladonna, physostigmine, Indian hemp, and other analgesics, com-
bined with rest and warm baths, are often successful. Section of the pos-
terior roots is the only radical cure known for visceral crises, but conteaiy
to what one would expect, this operation often fails to relieve pain.^

Whenever the posterior colanms of the spinal cord are afleoted* whether primarily
or secondarily, an ataxic gait and other symptoms resembling tabes may arise. Severe
anemias and other toxic debilitating conditions may bo complicated, as Dr. James
Taylor and others have shown, by posterior sclerosis and ataxic gait. In alcobofie
Bubjects there is at first a more or less transient ataxy, which later on, as posterior
sclerosis ensues, becomes permanent. There are four named diseases of thb sttsal
CORD, all of which, compared with tabes dorsalis, are relatively rare, but give rise to is-
co-ordination of the gait resembling tabes — viz., spinal pachymeningitis, spinal tumovr
involving the posterior columns. Friedreich's disease, and ataxic paraplegi*.

* Professor Forster and Mr. E. Hey Groves, the Lancet, July 8, 1911.

§§ 679. 580 ] SPINAL PACH Y MENINGITIS— FRIEDREICW8 DISEASE 823

! 679. Spinal Pachymeningitis, or chronic thickening of the meninges, ia apt some-
times to be confined to, or at any rate to predominate in, the posterior region of the
theoa vertebralis, and in some cases I have seen gave rise to disordered gait and other
symptoms which it was impossible to distinguish from those of tabes dorsalis. I
believe that many cases of so-called tabes cured by iodide were possible instances of
this affection of syphilitic origin (cp. § 560). One is assisted in reoognising this con-
dition if there is the long history of continuous pain and tenderness in the spinal
oolumn, and continuous pain shooting down the spinal nerves. These considerations
have led me to describe as a separate condition —

Pofterior Spinal Paohsrmeningitif. — It is extremely chronic, and not infrequently
the symptoms are few and ill marked, on which account such cases very rarely find
their way into hospitals. They get into the infirmaries, however, and my experience
at the Paddington Infirmary led me to the'Conclusion that the disease is fairly common.
At a meeting of the Neurological Society of London held at the Paddington Infirmary
in 1890, I was able to show the cords of five fatal cases and three examples of the
affection during life. Here is a fairly typical case : A woman, est. seventy-two, was
admitted into the infirmary in January, 1890, with all the classical symptoms of
tabes preceded and accompanied by very severe lightning pains. The history, briefly*
was that for three years prior to admission she had suffered from paroxysmal pain
shooting down the legs and various other places, and that she had had other attacks
which resembled gastric crises. For two years prior to admission she had suffered
from ataxy which became progressively worse, and at last so marked that she was
unable to stand. Many careful observers saw the case ; all had no doubt it was an
example of locomotor ataxy occurring in a woman. She died of pneumonia in June.
1891. and at the autopsy, though the pia mater and arachnoid on the anterior surface
of the cord was normal, that on the posterior surface was thickened and opaque.
This thickening was irregularly distributed from end to end, and was much more
marked in certain patches of 3 inches in length in the mid-dorsal and in the lumbar
regions, in which positions it was about the thickness of a piece of wash-leather, and
showed commencing calcareous plates. These patches were firmly adherent to the
posterior aspect of the cord, and the posterior columns beneath were sclerosed as in
cases of advanced tabes.

Spinal Tnmonr (intra- or extra-rachidian) pressing on the back of the cord, especially
in the lumbar region, is often attended by ataxic symptoms closely resembling those of
tabes. It may be distinguished from tabes (i.) by the absence of the pre-ataxio
symptoms mentioned above ; (ii.) by the fact that it is preceded by severe, constant,
neuralgic pains in the spine, spreading upwards from the lumbar enlargement ; (iii.) as
in other cases of spinal tumour, all the symptoms — which, be it noted, include actual
weakness and often stiffness of the legs — have a tendency to be unilateral — i.e., pre-
dominate in one other leg.

§ 580. Friedreich's Disease (Hereditary Ataxia), is a rare hereditary condition
ocourring in children, often sisters and brothers of the same family. These cases have
five differential characters, (i.) The ataxy is often most marked in the arms. There
is inability to stand with the eyes shut, sometimes loss of patellar ^reflexes, and other
symptoms characteristic of tabes. The disease, in short, presents a mixture of the
symptoms of disseminated sclerosis and tabes ; and pathologically it has been shown
to be a postero-lateral sclerosis. The knee-jerks progressively diminish as the disease
advances. There are, however, no lightning pains, no crises, and no Argyll-Robertson
pupil, (ii.) Tremors of an ataxic nature come on later in the arms, so that the hand
in approaching the mouth does not reach its goal, and is accompanied by jerky, ir-
rog^ular movements of the head and neck, (iii.) The speech is impaired in the same
manner as in disseminated sclerosis, (iv.) Nystagmus is present in most cases
(v.) There is usually no mental change. The muscles become weakened, and de-
formities such as scoliosis and talipes ensue.

Ataxic Paraplegia is another rare affection, which corresponds, in my belief, to the
spasmodic tabes dorsalis of some authors. It is due to sclerosis affecting the posterior
as well as the lateral columns, and it results in symptoms of the two lesions. It is
differentiated from tabes by the spastic rigidity, increased knee-jerks, and ankle-
olonus. The Argyll- Robertson pupil and lightning pains are absent. As time goes
on, the rigidity becomes more marked.

824 THE NERVOUS SYSTEM [ {§ Ml, Stt

§ 581« In Oerebellar Lefiions the gait is sometimes ataxio, but more often
staggering. These lesions may be obscure, but they may be suspected in
presence of a group of four symptoms — viz., a reeling gait, headache, vertige^
and nystagmus — especially when those symptoms occur in childhood. The
walk is fairly characteristic, having a reeling character, and Uie patient
tends to sway from side to side like one intoxicated. But sometimes,
especially when one lateral lobe is affected, the patient tends to fall over
towards the side of the lesion. There is frequently weakness, without
actual paralysis, sometimes hemiplegic, but more frequently parapl^c, or
general in its distribution. The knee-jerk does not help us, for it may be
absent, increased, or normal. The cranial nerves mostly afiEected are ^
fifth, sixth, and the optic nerve. A symptom occasionally present is
forced muscular movements of the neck, pulling down the head towards
the side on which the lesion is situated, in tumour of the lateral lobe.
Other occasional s3rmptoms are attacks of syncope, palpitation, and
dyspnoea, which are of considerable gravity, as they indicate pressure cm,
or extension to, the medulla, though in one instance of this kind the patient
(on whom I made the autopsy) lived for one year and ten months after
the onset of these symptoms. Tenderness or (later) bulging may be
detected in the affected region.

The Prognosis and Treatment of cerebellar tumour is that of odier intra-
cranial tumours. Its deep-seated situation and the proximity of the
medulla render it one of the most serious of intracranial tumours. In a
few cases the tumour has been successfully removed.

(y) Increased Musoulab Action.

Involuntarily increased muscular action may be —

Continuous, when it is known as rigidity or tonic spasm § 582

Intermittent, when it is known as tremor if the movements are small
and vibratile, and clonic spasm if the movements are large . § 589

Attacks of violent muscular movements, associated with more or less
disturbance of consciousness, are known as convulsions . . § 597

The paiicfU presents a continuous stiffness or rigidity in the affected rmuada
— ToNio Spasm.

§582. Tonic Mnscnlar Spasm or rigidity is indicative of an irritative
lesion, functional or organic, in some part of the motor tract, or a morbid
irritation in the muscular substance. It occurs in the following conditions :

I. Paralytio rigidity (eariy and late).
11. Hysterioal rigidity.
lU. Oooupation oramp.
IV. Cramp.
V. TetaDUs.
VI. Tetany.
VII. Hydrophobia.
VIII. Thomsen's disease.
IX. Arthritio rigidity.

588,684] PARALYTIC RIQ1DITIE8 OF ORGANIC ORIOIN 825

The first of these causes is of organic origin ; the second, third, and fourth are func-
tional ; the fifth, sixth, and seventh are toxic ; the eighth is due probably to some
hereditary defect ; and the ninth is probablyjreflex.

§ 688. Paralsrtic Rigidities of Organic Origin are associated with paralysis,
and are of three kinds, as exemplified in hemiplegia.

1. Early Rigidity of the muscles is that which comes on with the para-
lysis in cases of hemiplegia due to hsamorrhage, or within the next few days
in association with irritative lesions such as pressure on the anterior spinal
roots. The rigidity of haemorrhage comes on suddenly, and passes off
gradually in the course of a week or so. The rigidity of other irritative
lesions only passes oft when the irritation is removed or the nerve-tracts
destroyed.

2. Late or Spastic Rigidity of the muscles is that which comes on gradu-
ally in the course of a month or so in all cases of paralysis due to lesions
of the upper motor neuron. It is met with typically in hemiplegia, spastic
paraplegia, and all lesions followed by descending lateral sderosis in the
spinal cord. It is always associated with increased knee-jerks, ankle-
clonus, and Babinski's sign ; tremors or clonic muscular spasms or athetosis
may also be present. It comes on gradually, and increases progressively.
It diminishes during sleep. Chloral hydrate relieves this kind of
rigidity, which is sometimes very troublesome and painful in hemiplegic
cases.

3. Organic Contracture ensues in all paralysed muscles in the course of
years, whether of the upper or lower neuron type (such as hemiplegia
and infantile paralysis respectively). It is due to an atrophic fibrosis
of the substance of the paralysed muscles.

Hysterical Rigidity may easily be confounded with 1 and 2 above, unless
the history is accessible. It generally comes on quite suddenly after an
emotional storm. It is often of limited extent, involving perhaps only
the wrist-joint. It may pass ofi as suddenly as it came. It rarely lasts
long, but may occasionally persist for years. This rigidity is said to
persist during sleep. The patient, who is a female, presents other signs
of h3rsteria.

§684. Oecapation Cramp and other Oeoapation Nenroses. — ^We have
already seen that exhaustion produces muscle-cramp. The continual over-
use of a certain group of muscles is apt to produce five symptoms, at first
localised to that part, but tending ultimately to spread to other muscles,
if the cause continue in operation. In order of frequency, they are (1) tonic
spasm, (2) paresis, (3) pain, (4) tremor, and (5) in some cases either atrophy
or hypertrophy follows.

Writer's Cramp is the most frequent example, and may be taken as a
type, but what follows will apply almost equally to other occupation
neuroses, (i.) Tonic Spasm, — ^In scrivener's palsy, after writing for some
time, the fingers get so stifi that the patient cannot write. Sometimes
the spasm is very painful, and occasionally there are twitchings. The
character of the writing alters, and in the course of weeks or months the

826 THE NERVOUS SYSTEM [|

slightest attempt at writing produces a tonic spasm in the muscles used
for that purpose. For a long time tonic s^asm afftara only on aUempiing
to tprite, the part in the intervals being quite free from symptoms, but in
the later stages the spasm may become persistent or start spontaneously.
In the later stages also the spasm is apt to spread from the hand to tiie arm,
shoulder, neck, and other parts. In the early stage the general uses of
limb are unimpaired, and a patient affected with writer's cramp may paint,
or play the flute, but in most cases other delicate manipulative procedures
cannot be performed with the same precision as formerly, (ii.) The
Power of the grasp as tested by the dynamometer, is said to be nomuJ,
but this is not a delicate test of the small muscles in writing. By careful
examination, I have very rarely failed to detect some loss of power. Poore *
also insists that definite slight weakness of certain muscles of tbe band ii
not uncommon, (iii.) Some discomfort is always experienced and this
sometimes amounts to actual pain. This pain, moreover, has a great
tendency to spread. In some cases the pain is the most pronomieed
feature of the case, and is accompanied by tenderness of the nerve-tnmks,
and tender points elsewhere (occupation neuralgia). '' Pins and needles ^
and other subjective symptoms are by no means uncommon, but I am not
aware that anaesthesia is ever observed, (iv.) Atrophy is said to be rare,
but a careful comparison of the interossei and other muscles of both hands
in several cases has convinced me that it does sometimes occur. Hyper-
trophy is much more frequent ; it usually follows cases in which spasm is
the leading feature, (v.) Electric irritability is slightly increased in tiie
earlier stages, and slightly diminished in the later to both faradism and
galvanism, in the muscles and the nerves (Gowers). (vi.) Twitchings and
clonic spasms are only occasionally observed, but tremor and unsteadiness
are common.

Course and Prognosis, — The advent is very gradual, and the course
prolonged over many months or years depending on the continuance of
the cause. The prognosis depends on (i.) the duration of the affection
and stage when the treatment was commenced ; (ii.) the means of the
patient to cease the occupation ; and (iii.) his intelligence in grasping tbe
principles of treatment.

The DiagnosiSy by reason of its association with the occupation, is
^ot usually difficult, but there are several organic and functional
disorders which may be mistaken for writer's cramp at their outset.
Brachial neuritis (q.v,)y lead palsy, and even disseminated sderosis
may be mistaken for it, but in these careful inquiry shows that
even from the first the S3niiptoms were not solely determined by the
act of writing.

Treatment. — The disease is more frequent in nervous, sensitive personi
especially when suffering from a general '* lowered tone," or malnutrition,
anxiety, or grief. There is also a distinct tendency in persons of a neurotie
family history. The fact that there is but one determining cause shouM

^ Vivian Poore, the Practitioner , 1878. and Med. Chir. Trans., vol. 61.

§685] OCCUPATION OB AMP 827

render the treatment comparatively simple, but, as a matter of fact, it is
very difficult because the malady is chiefly found in those whose daily
bread depends upon the performance of a certain muscular movement*
Careful re-education can, however, accomplish a great deal, and particu-
larly the adoption of a freer and larger style of writing, by holding the pen
more loosely and in a different way. The patient should learn to hold the
pen between the first and second fingers with the back of the hand against
the paper, and practise writing a series of large sloping M's. A certain
amount of rest — at any rate, at the outset — is indispensable. Mean-
time the patient should b^in learning to write with his left hand.
Sedatives are of service, especially in neuralgic forms, such as chloral,
bromide, small doses of morphia, physostigma, Indian hemp, belladonna,
or atropine (yj^ grain hypodermically two or three times a week). Nervine
tonics are reconmiended, and even strychnine, but I have often observed
this remedy do more harm than good. Faradism also does harm, but
voltaic electricity has often seemed to me particularly beneficial, especially
when combined with massage. Gymnastic exercises are strongly advo-
cated by some. One remedy — cod-liver oil — ^has rendered great service,
and some of the most successful cases I have seen have been treated by a
combined method of moderating the amount and improving the style of
the writing, and the adminbtration of small doses of bromide and cod-liver
oil. In many cases dyspepsia or a rheumatic or gouty taint is present,
which should be met by appropriate measures.

Other Oeoapation Neuroses resembling the foregoing are found among
telegraphists, drapers (in using scissors), cigarette rollers, violin-players,
piano-players, typewriters — any occupation, in short, which necessitates
the constant repetition of one particular movement.

Oramp is a tonic mnaoular spasm occurring in one or more muscles of a limb. It is
a troublesome symptom of not Itifrequent occurrence in persons apparently in good
health. It is most apt to come on at night. A muscular cramp of great severity may
seize one or all the limbs, and even the respiratory and trunk muscles of a swimmer,
and prove very deadly unless aid is close at hand. It is apt to come on in those whose
muscles are exhausted, but a low temperature of the water plays some part. Some
persons s^m prone to be affected by cramp throughout life on slight causes, such
as lying with the limb in a strained position. Others only suffer from it when their
digestion or general health is out of order. The best rem^y is to get out of bed and
gently move and rub the limb. Bromide and chloral hydrate will generaUy prevent
its ooourrence, and any lithemia, gouty or rheumatic tendencies should be corrected.
Cramp is a frequent premonitory symptom in peripheral neuritis and phlebitis. It is
also met with in subjects of Bright*s disease and gout, and cramp of the legs is a painful
symptom in the first stage of cholera.

§ 585. Tetanus is a severe disease characterised by paroxysms of tonic and some
times clonic spasms, due to the inoculation into a scratch or wound of a specific microbe
whose ohief habitat is in the earth.

Symptoms. — (1) Within a few days after the injury the patient complains of stiff-
ness of the jaw and back of the neck. (2) Very soon these muscles become rigid.
The condition of the jaw is known as trismus, or lock-jaw, in which the jaws cannot
be separated. This tonic rigidity affects all the muscles of the trun k, and in a less degree
of the extremities. The back is rigid, sometimes arched in the position of opisthotonos,
ill which only the head and buttocks rest on the bed. Or there may be flexion to one
side — pleurosthotonos, or bending forward of the body — emprosthotonos. The angles of

828 THE NERVOUS SYSTEM [fW

the mouth are drawn down and the eyebrows are elevated — risus sardonicus. (3) Qook
spasms supervene from time to time, in which the already rigid muscles beoome mocc
contracted, with agonising pain. The slightest touch may causs clonic spasms. In
severe oases these spasms beoome more frequent, leading to death from InvoWeBint
of the glottis or respiratory musdes. (4) 1^ temperature may be normal or sli^tfy
raised throughout, and may rise to 108^ F. just before death. There is often retentaoe
of urine. 1^ mind is clear till quite the end. A variety due to head wounds is de-
scribed, with paralysis of the facial muscles and difficulty in swallowiiig.

Diagnosis. — In hydrophobia the spasm is at first clonic. It affects chiefly tkt
muscles of respiration and deglutition, and there is more mental agitation than is
tetanus. In strychnia poisoning in the intervals between the spasms the mnsdei
relax, and the spasms involve the extremities to a greater degree. In spinikl meningHiB
there is a temperature, and there is no trismus. Tetany does not resemble tetanw
In hysterical opisthotonos there are other evidences of hysteria. Trismus is caased
also by disease of the pons and acute bulbar paralysis, and in association with peri-
ostitis of the jaw, disease of the temporo-maxillary joint, or other local iiritation ;
but the course of the disease Serves to differentiate these from tetanus.

Prognosis, — Death occurs in acute stages in one to twelve days from exhaustion or
involvement of the glottis or respiratory muscles. In more chronic cases the
become less frequent, and recovery ensues in two or more months. If the
does not start till more than twelve days have elapsed since the injury, the outiook ii
not so hopeless. The mortality is very high — about 90 per oent.

Etiology. — ^Tetanus is caused by a wound, however trivial, into which the tetaaai
bacillus has entered. The bacillus has its habitat in the earth. ^ Tetanus of the new-
bom is due to want of aseptic precautions in treating the navel.

Local Treatment of the wound is necessary by cautery or antisepsis. For the spasms.
chloroform, bromides, chloral hydrate, and other drugs are given, and reooverias have
been reported after their use. The tetanus antitoxin has given good results in the
subacute cases. For acute oases, unless given very promptly, it is not so usefuL In the
United States a large annual mortality from tetanus has been practically abolished by
the prompt use of antitoxb. It oan be introduced through a trephine hole in the
skull ; it may also be given by lumbar puncture (§ 626). li^^esium sulphate injec-
tions (5 c.c. of a 20 per cent, solution) by lumbar puncture check the convulsions.
but are not curative.

§ 686. Tetany is a muscular stiffness occurring in paroxysms, affecting mainly the
ends of the four extremities.

The Symptoms come on mostly in infancy in the form of a muscular spasm, or, to
be more correct, a paroxysmal stiffness affecting both the forearms, hands, and feet.
The attitude of the fingers compressed into a cone (the accoucheur's hand) has been
emphasised, but it is unessential ; it is the attitude assumed by athetosis and many
other tonic spasms. The paroxysms last from a few seconds to an hour or so, and in
severe cases there is no intervening relaxation. In severe cases, moreover, all iht
muscles of the body are affected, and there may even be opisthotonos. There is a
good deal of neuro-muscular irritability to compression and to both forms of dectricity,
and if the nail be drawn down the face, a wave of muscular contractility foUows it
(Ohvostek's sign). Many degrees of severity are seen, and the disease may only last
two days or two or more months, recovery being the general but not invariaUe rule.
The Diagnosis is not difficult. In tetanus the spasm mainly afifects the jaw, and
there is a history of injury.

Etiology. — ^Tetany is most frequent in children the subjects of rickets or diarrhoBa,
or other gastro-intestinal disturbance, but it is not solely confined to childhood. In
adults it is particularly associated with dilatation of the stomach' or any other gastro-
intestinal condition attended with fermentation. Cases have been noted in associa-
tion with pregnancy, albuminuria, and after removal of the thyroid. The disease is
almost certainly due to a muscular toxin.

^ The Lancet, November 24, 1888.

^ For a carefully studied fatal case of tetany following dilatation of the stomach,
see J. S. MoKendnok, the Lancet, September 24. 1898.

§§ 687-589 ] TREMORS AND CLONIC SPASMS 829

The Treatment should be directed to the causal condition. Bromide, chloral
hydrate, and immersion in cold water (unlike Thomson's disease) will relieve the
spasm.

J 587. HydrophobU is a contagious disease characterised by spasms ol the muscles
of deglutition and respiration, and due to inoculation by the saliva of an animal suffer-
ing from rabies.

SymptofM, — (1) After an incubation stage, during which the patient presents no
symptoms, which is generally about six weeks, never less than twelve days, and may
even last as long as twelve to eighteen months or more, there is an insidious onset
of malaise, with perhaps slight fever, and sometimes tinging in the wound. (2) With
or without premonitory s3rmptom8 paroxysms of painful spasms of the pharynx super-
vene, coming on at first with a slight stiffness, and brought on by any attempt to
swallow. (3) These ^t&sn^> At first clonic, become tonic, lasting a quarter to half an
hour at a time, and spread to the muscles of respiration and of the neck. The attacks
produce excruciating pi^ and agony of mind. The mind is quite dear, but in the
intervab there are prostration and general hypersesthesia. (4) Paralysis ensues in
three or four days' time, first of the muscles of the lower jaw, and death follows within
a week from the onset.

Treatment, — ^To destroy the virus at the seat of entrance suction immediately after
the bite is heroic, but efficacious. CSauterising the wound may be employed. The im-
munisation treatment of Pasteur is dealt with in § 386. Narcotics, chloroform inhala-
tion, and chloral may be employed.

§ 688. Thoms«ik'i Diseate (Congenital Myotonia) is a rare and obscure condition ol
universal muscular stiffoess of indefinite duration, aggravated by rest. Tension and
stiffness of the limbs are experienced on first attempting to rise alter resting, but they
relax to some extent after continued movement. The muscles of the lower extremities
are affected most, but those of the face, tongue, and eyes may be similarly involved.
The stiffness is increased by cold. Sometimes there appears to be slight hypertrophy,
never atrophy. The galvanic reactions vary, but faradism is never lost, and this
leads to the idea that the disease is in the muscles, not in the nerves. The malady is
noticed for the first time in youth, and is very probably congenital. Several members
of a family may be affected. The disease does not appear to shorten life. Warmth
and continued activity relax the spasm to some extent.

Arthiitie rigidity is known by its being associated with some joint lesion, though
the latter may be very slight. It affects both the extensors and flexors of the
joint, though chiefly the flexors. I have usually noticed that it is increased during
sleep.

There are iiregnlar mOFoments or shaking of the affected musdesy the
range of the movements being either small (Tremor), or large (Clonio
Spasm).

§ 689. Tremors and donio Musoular Spasms form a very frequent and
pronounced symptom in many different nerve lesions. For clinical pur-
poses abnormal muscular movements may be divided into tremors or move-
ments of small size, and clonic spasms or movements of larger range;
paralysis agitans may be regarded as a type of the tremors, chorea as a
type of the clonic spasms. The symptoms we are now considering must
not be confused with generalised convulsions or fits (§ 597), nor with the
uncertain movements of paralysed limbs or tabes dorsalis.

Classification, — It will be convenient to consider first the dbeases in
vrhich tremors occur (such as paralysis agitans), and later the causes of
clonio spasms (such as chorea). But this division must not be taken too
Eibsolutely for those which are commonly small are occasionally apt to be
large, and vice versa.

880 THE NERVOUS SYSTEM |

Tbbmors. Clonio Spasms.

Partial Degenerations. Oeneralised.

I. Paralysis agitans. I- C^iorea.

TI. SenUe tremor. II- Hysterical spasms.

III. Disseminated sclerosis. HI- Myoclonus multiplex.

Functional. Localised.

IV. Hysterical trembling. IV. Habit spasm.

' V. Facial spasm.
ToxcBmic. VI. Spasmodic torticollis.

V. General paralysis of the insane. ^^- ^*'^' ^"^^^ "P"™""

VI. Alcoholic tremor. ^^^

VII. MetaUic tremor. Urgamc.

VIII. Other toxic conditions. | VIII. Post-paralytic clonic Bpa^nu.
IX. Nervous or neurasthenic tremor,

and Graves' disease. j

Organic. I

X. Organic diseases in which tremor
is not always a prominent '
feature : '

(1) Post-paralytic tremor. '

(2) Amyotrophic paralysis.

(3) Liateral sclerosis, Fried-

reich's disease, and
other degenerative con-
ditions.

Clinioal IifrvBSTiaATiOK. — ^The more important points to be observed about
of tremor or clonio spasm (in addition to their size or range, as just mentioned)
1. Their distribution, which may be localised to one limb, as in hysteria, or generaliard,
as in alcoholic tremors

2. The rhythm or regularity of the tremor should be noted ; for example, it is regulav
in paralysis agitans, senile tremor, disseminated sclerosis. Graves* disease, small
hysterical tremors, alcoholic and metallic tremors ; whereas it is irregular in the variom
forms of chorea and in some functional conditions.

3. It should always be ascertained whether the tremor is present when the limb is
resting on the bed or table, or only when the muscles are in action. Some kinds of
tremor come on only during muscular action, as in disseminated sclerosis. This is
known as intention tremor. Other kinds of tremor, such as paralysis agitans, pensst
during muscular rest — e,g., when the limb is laid on a table. It should, however, be
borne in mind that all kinds of tremor tend to be increased when the muscles are
thrown into action, or when the patient's attention is directed to them, or during
emotional states.

4. The mode of advent does not afford much valuable information. It is apt to be
sudden in all forms of hysterical and functional spasm, but in most of the remainder
it is gradual.

5. The age of the patient often gives us an important doe, for among the various
causes paralysis agitans and senile tremor are uniformly found among the aged;
whereas alcoholic tremor, metallic tremor, and paralytic dementia invariably affect
persons in the middle decades of life ; and, finally, hysterical tremor, chorea, dis-
seminated sclerosis, and habit spasm are mostly met with in the comparatively
young.

6. Causation and Pathology. — All tremors and clonic spasms may arise under one
of three pathological conditions : (1) Some organic lesion of the nervous system, tneh
as disseminated sclerosis ; (2) idiopatiiic or toxsmic causes, such as general debility.
anaemia, alcohol, hysteria, syphilis, rheumatism, or other toxic conditions ; or (3) reflex
irritation, such as may be seen in the case of facial spasm or habit spasm, when the

§ 600 ] PARALYSIS AGITANS 831

ti(emor may disappear on the removal of a diseased tooth or oocreotion of the refrac-
tion of the eye, or, as in a case I have seen, remedy of disease of the pharynx.

A study of the organic oases throws much light on the pathology of tremors and
clonio spasm, for we find that they are always dae either to partial destruction or
imperfect reoovery of some part of the motor tract. The greater frequency of post-
hemiplegic clonic spasms (1) after embolic lesions, which are less destructive than
hemorrhage ; (2) after hemiplegia associated with hemianssthesia which indicates a
lesion far back in the internal capsule ; and (3) after the hemiplegia of children, in
whom the recuperative power is so much greater — all point to this conclusion. Turn-
ing to other diseases, we see that insular or disseminated sclerosis is attended by an
incomplete destruction of the motor tract. Paralysis agitans, again, is evidently one
of the senile degenerations, which is very gradual, and therefore for a long while
incomplete. Later on in this disease, when the motor fibres are more completely
destroyed, the tremors cease, and paralysis, with tonic rigidity, ensues. Finally, it
may be seen what a very large proportion of the causes of tremor and clonic spasm are
of tezffimic, idiopathic, or functional origin, and it is in just such functional causes
where one would find only partial destruction (or partial recovery) of the motor tract.

§ 590. I. Paralysis Agitans (Synonyms : Shaking Palsy, Parkinson's
Disease). — The onset is extremely gradual, and the three cardinal symp-
toms are (i.) tremor, which is moderate in size, rhythmical, and of general
distribution, excepting the head and neck. The fingers and thumb are
approximated in a "pill-rolling" movement. Dr. Purves Stewart has
pointed out that the toes have a similar tendency to curl over the sole.
The tremor continues when the limbs are supported. Not infrequently it
predominates on one side of the body, or in the arms and legs, and the
onset b often accompanied by " rheumatic " pains — facts which point to
a degenerative lesion in the peripheral nerves.^ (ii.) The muscles gradu-
ally become stiS, and the attitude and aspect of the patient (Fig. 4, § 15)
are very characteristic. The head appears to be fixed, and is bent a little
forward ; and the patient walks and turns round rigidly, as if " made of
glass." The gait is characteristic ; the patient walks faster and faster,
tending to fall forward (festination). If pushed backwards, he continues
to walk backwards, unable to stop until he meets an obstacle (retropulsion).
The patient's face appears like an expressionless mask with the eyes
always looking forwards, (iii.) The patient is nearly always over forty
years of age, and, in 65 per cent, of the cases, of the male sex. (iv.) The
other and less important points for differential purposes are progressive
weakness, which gradually involves all the limbs ; the speech, which is
drawling, indistinct, monotonous, and slow ; and various subjective sensa-
tions, such as restlessness and a continuous desire to be moved, if in bed.
The intellect is preserved, and though the disease lasts for many years, it
does not usually shorten life. No complaint is made of vertigo or nystag-
mus. Towards the end of life the tremor disappears, and is replaced by
paralysis, rigidity, and contractions.

The pathology of paralysis agitans has not been completely settled,
but some years ago Dr. Robert Maguire and the author, by examining the
nerves after death, found varying d^rees of degeneration in the different

^ In one case Dr. Robert Maguire and the author found after death degenerative
lesions in all the chief peripheral nerves.

832 THE NERVOUS 8Y8TEM JiU

peripheral nerves and other parts of the nervous system. In view of the
remarks in § 589, this would fully explain the symptoms. It seems prob-
able that the degeneration is a prematurely senile one — ^just as premature
senility may afCect the arteries.

A Senile tremor is described by some, but in the couise of a laige infinnaiy experi-
ence I was rarely able satisfactorily to differentiate paralysis agitans from senile tremor.
However, in the latter the tremor always involves the head and neck, being, indeed,
sometimes most marked in or limited to this situation, and rigidity and pareais ire
less marked.

§ 691. Diiseminated Soleroiit. — Islets oi sclerosis in the spinal oord were described
by Cruveilhier as an anatomical condition, but the clinical symptoms attaohing to the
condition were not described until Professor J. M. Charcot studied this oonditioa
clinically, and gave to it the above appropriate name. There are varioua types of
the disease recognised, according to the part chiefly involved. The three character-
istic symptoms of this disease are (i.) the tremor, which is very rhythmical, rather
larger than paralysis agitans, and occurs only when the muscles are in action, ceasing
when the limb is supported. This is, indeed, the most typical of " intention tremors..''
It involves all tne muscles, including those of the head and the tongue. The intentioa
character differentiates the tremor from paralysis agitans, and it may bo distinguished
from chorea by the fact that the arm goes straight to its goal, as, for instance, in
feeding, whereas in chorea it takes a zigzag course, (ii.) The patient is usually under
thirty (the earliest case I have observed was sixteen years old). It rarely oonunencn
in persons over forty-five or fifty years of age. The sexes are equaJly affieeted.
(iii.) The speech is characteristic, being slow and syllabic — i.e., pausing between the
syllables of a word and clipping the labial consonants. There is a torpid condition of
the intellect, especially in those oases where the brain is also involved, (iv.) Vertigo
is also an important and early symptom, occurring in something like 70 p^ cent, ol
the cases, (v.) Nystagmus is another constant symptom, and it is often accompanied
by primary optic atrophy (white atrophy), (vi.) Various other symptoms may anae.
according to the position of the patches of sclerosis. Thus, if the lateral columns be
much involved, we get spastic symptoms ; if the posterior columns, tabetic, and so on.
In an analysis of fifty cases. Dr. F. S. Palmer^ found that weakness, especially of one
limb only, was the first sjrmptom noticed in the disease in fifteen oases. The patellar
reflexes are usually increased, but they may be normal or diminished. Their absence is
serious, as denoting involvement of the grey matter. The abdominal reflex is absent^
whereas all the others tend to be increased. Various sensory disturbances may also
be observed, (vii.) The course of disseminated sclerosis is prolonged ; it may last
from two to ten years, being longest in the purely spinal form, shortest in the cerebvo-
spinal form.

Hysterical Tremor is a very frequent manifestation of that diathesis. It may be
small and regular or large and choreiform (see below).

General Paralysis of the Insane has been fully described in Mental Disorders. Here
the tremor is very fine, regular, and vibratile, and it tends to affect the lips and tongue
more than any other parts ; indeed, at first these alone may be involved. It is accom-
panied by more or less general weakness and by characteristic mental alteration.

Alcoholio Tremor is one oi the most constant evidences of chronic alcoholism. It
is especially noticeable in the hands, is small and vibratile, rhythmical, dependent on
muscular action (intention tremor), and worst in the morning. There is also a histoiy
of dyspepsia with morning vomiting, insomnia, and other evidences of chronic alco-
holism.

Metallic Tremor. — Mercury, lead, and zinc, especially when introduced into tlie
system in the form of vapour, or in small doses for a considerable length of time,
not infrequently produce tremor. It is small, rhythmical, and only apparmt when
the muscles are in action. It is also characterised by the other sig^ of poisoning by
the respective metals. Mercurial tremors occur, for the most part amongst thenno-

^ " Early Manifestations of Insular Sclerosis,*' Med, Press and Circvkur, Septtm-
ber 7, 1904.

§ 698 ] QA USE a OF TREMOR 883

meter-makers, and water-gilders in the manufacture of mirrors. Lead tren^rs
ocoor largely amongst the Cornish and Cnmbei^and lead-miners, and zinc poisoning
amongst brass-foanders, who are exposed to the fumes of oxide or oxyoUoride of
zinc.

Other toxAmio conditionf are also attended by tremor, such, for instance, as diabetes,
malaria, influenza, trypanosomiasis, and pyrexial states. Here the tremors are small
and rhythmical, and a history of the cause is easily made out. Qrayes' disease is mostly
attended by a fibrillary tremor, and in such cases inquiry should be made for thyroid
enlargement, ocular prominence, cardio- vascular phenomena, and other neurasthenic
sjrmptoms, the tremor being really one of these.

Menronf Tremor arises from debility either of the muscular or nervous system, and
is seen in its most typical form in cases of ntar<iBihen%a or general debility from any
cause, mider which headings the other characters of the various causal conditions arc
desoribed. Tremor may also be present in occupation neuroses.

There are organic diieases in which tremors occur, but these are usually accom-
panied by other more prominent symptoms, as in amyotrophic paralysis.

Tumour of the brain may be accompanied by musctdar movements, especially
(i.) when the tumour presses on, without actually destroying, some part of the Motor
Tract — e.^., in children who are the subjects of a tuberculous tumour near the crura
or the posterior part of the internal capsule — there is tremor exactly like that of
disseminated sclerosis, (ii.) If it bo situated in the Parietal Begion or near the Optic
Thalamus, the tremor usually takes the form of spastic athetoid movements.
<iii.) Cerebellar lesions may be associated with spasmodic movements of the neck
muscles on one or other side, (i v. ) Some lesions in the Frontal Region may be attended
by a fine tremor of the hand on the same side (T. Grainger Stewart), (v.) Lesions of
the Bed Nucleus or its connections with the Cerebellar Dentate nucleus of the opposite
side or with the anterior horns below are attended by tremor.

Lateral sclerosis often gives rise to tremor of the legs on walking or any muscular
movement.

Friedreich's disease is characterised by tremor or by disorderly movements.

§ 592. Chorea (St. Vitus' Dance, Sydenham's Chorea) is a disorder of
the nervous system occurring generally in childhood, characterised by
irregular awkward movements of the limbs and a tendency to cardiac
valvular disease, running a more or less definite course usually towards
spontaneous recovery. It was first described by Sydenham in the seven-
teenth century.

(1) The movements usually partake more of the character of gesticula-
tions or exaggerations of normal movements than of tremors or even clonic
spasms. In carrying a spoon to the mouth, the hand does not reach its
goal, as it does in disseminated sclerosis. The movements may involve
all the muscles of the body, even those of deglutition, the face, the tongue,
and respiration, including the diaphragm. They are sometimes hemi-
plegic in distribution, and may predominate in the upper extremity or
the face. The movements cease during sleep. The deep reflexes vary.
(2) A certain amount of paresis may accompany or alternate with the
movements, and the chief symptom for which many pati^its are brought
is because they drop things or fall down. Sometimes they are brought
for restlessness at school. Very severe cases may develop maniacal
symptoms. Eruptions on the skin (erythema, herpes zoster, purpura,
and subcutaneous nodules) have been observed. (3) It is also accom-
panied, in a large proportion of recurrent cases, by valvular disease, which

is indistinguishable from that of acute articular rheimiatism.

834 THE NSH V0V8 8 Y8TEM [ W

The Diagnosis from habit spasm is occasionally difficult, but the latta
is more persistent in duration, more United in distribution, and ^e in-
voluntary movements always afEect the same set of muscles. There is t
slight lymphocytosis in the cerebro-spinal fluid and increase of eosittophik
in the blood. It may also have to be diagnosed from various other donic
spasms mentioned below.

The Prognosis is usually favourable, and tends to spontaneous cure ii
the course of one to three months, though in about one-third of the cases
permanent cardiac disease remains, and 20 per cent, of all cases of chore*
get rheumatbm within six years.^ The severity of the attack dq^ends a
good deal upon the age of the patient. Over the age of puberty die
disease assumes a much graver aspect, and is very apt to be recurrent;
and when it complicates pregnancy in young women the mortality b
about 30 per cent. Great severity of movement, recurrence of attadc, uid
maniacal symptoms (chorea insaniens) are always grave.

Etiology, — The disease is essentially one of childhood, and is three tima
as frequent in the female. There b a special liability for chorea to foUov
articular rheumatism, quinsy, scarlatina, and to a less extent other infec-
tive disorders. For many years I have taught that chorea was microbic
in origin, and pointed out in proof (1) the practical limitation of the
disease to childhood ; (2) its more or less definite course and t^idency to
spontaneous recovery ; (3) the marked tendency to endocarditis, and (4) the
spread of the disease to other children by so-called " imitation." In 1903
Dr. J. F. Poynton revealed the rheumatic diplococcus in cases of chorea,
and the disease is now coming to be regarded as microbic. As in riieuma-
tism, there is a marked tendency to recurrence, and it is predisposed to by
many of the same conditions as the acute specific fevers. Fright or other
sudden emotion may determine an attack.

Treatment. — Salicylates as first introduced by Dr. David B. Lees, ad-
ministered in the same way as in rheumatism, are almost as successful in
chorea. Aspirin and quinine have been tried. The patients must be
taken from school, and do far better in bed even in slight cases. The
movements, if violent, may need bromides and large doses of chloral
(10 grains every two hours if awake) or trional; chloretone is valuable.
A water-bed is desirable. Arsenic in gradually increasing doses is the
best tonic, and may alone be sufficient to cure mild cases. A wet pack
and other methods for the application of heat or cold are excellent means
of treating severe oases (see § 596).

Hiintingdon'i Ohoreft (Chionio Gioroa, Hereditary Chorea) is oharacteriaed bj
Irregular gestictdatory movoments, coming on gradually between the thirtieth and
fortieth year, and lasting for the rest of life. The gait is irregular and swajring, witfc
sudden stoppages, the speech is affected, and there is mental impairment leading to
dementia. This disease runs in families. A similar affection coming on in the aged.
without hereditary cause, is known as senile chorea. Rhythmical and other forms of
chorea are mentioned below. It is unfortunate that the term ** chorea *' has beea
applied to these various conditions, which are totally distinct from Sydeokaa'f

^ Dr. F. £. Batten, the Lancet, November 5, 1898.

f m ] CHOREA— TIC 835

chorea. Henoch's chorea eiectrica is probably identical with paramyoolonuB multi-
plex (below).

Hjiterioal tremor and spasms are of different kinds. They may bo generalised,
like ohorea, or localised to one situation ; and they are aggravated by, but not de-
pendent on, volnntary muscular action. They are characterised by (1) their sudden
onset, generally after some emotional shook ; (2) they vary in size, rhythm, and even
in position from hour to hour and day to day ; (3) they have a tendency to predominate
in the head, neck, or arm ; and (4) they occur in a characteristic age and sex. A
typical case of this sort was that ola young lady, aat. twenty-four, whom I saw lately
with Dr. Alfred Masters, who had suddenly developed choreiform movements in the
right upper extremity while under the unusual influences of a long stay at her fiance's
home. The disorder consisted of a continuous regular tremor of the arm, intcrsi)ersod
with attacks of large irregular clonic spasms. The knee-jerks wore so much exagger-
ated that the patient almost jumped out of the chair. Another class of hysterical
spasm has been appropriately named chor^ rhythm6e by Charcot, in which condition
the movements are distinctly choreiform, more or less generalised, and differing from
ordinary chorea, first, by their coming on in attacks, or, at any rate, being liable to
severe exaoerbations ; and, secondly, by having' a tendency to a certain degree of
regularity. In one case of this kind which I observed^ these attacks could bo started
by pressure on the mamma, and they could bo stopped by steady pressure in the
ovarian region. In addition to those two forms, which might be called localised
hysterical spasms and chor^ rhythmic respectively, there are a large number of other
rarer kinds, which may be provisionally placed in the hysterical group, though their
procis3 relation to hysteria has not been made out. For instance, aalkUory spasm
(jumping chorea) is a rare condition of clonic spasms, affeoting principally the lower
extremities, which are usually in a state of more or less rigidity, and subject to violent
extensor spasms whenever the soles of the feet are touched, or when the patient is
placed upon the feet. The hands and arms are usually free. Hammering and dancing
ohorea have also been described by Charcot^ and others.

Myoclonus Multiplez (Synonym : Paramyoclonus Multiplex) is a very rare condition
described by Friedreich.^ Judging by the few cases that have been recorded, this con-
dition may be provisionally described as a disease consisting of attacks of sudden shook-
like clonic spasms, not usually sufficiently prolonged to produce tremor of the limbs,
bilateral, affecting mainly the proximal segments of the four extremities ; occurring
mostly in males, and running a chronic course. Spasms of larger range may occur.
It is probably duo to some congenital or hereditary defect, though it may not be
revealed for several years after birth. The most curious part of this strange disorder
is the exemption of the wrists, ankles, hands, and feet. It is usually relieved by fairly
strong galvanic currents, but is apt to relapse. The only case that I have soon had
lasted for nearly thirty years. Much confusion exists as to the identity of the diseaso.

§ 598. Spasmodic Tic is a recurrent, involuntary, clonic spasm afEecting
certain groups of the voluntary muscles, and producing twitchings which
at first are limited to one place, but apt to spread. Many names have
been applied to the condition — Habit Spasm, Convulsive Tic, Tic Non-
douloureux. Impulsive Tic (Gilles de la Tourette), Spasmodic Torticollis —
but they are essentially all the same. In the author's view their pathology
is similar, and depends on two factors : (a) An instability, natural or ac-
quired, of the subconscious and reflex centres ; (6) a repetition of a certain
movement or trick until it becomes first involuntary, then automatic, and
finally exaggerated. They also depend on the principle that nervous
impulses travel more easily along a track they have travelled before — e.g.y

1 Clinical Journal, October 19, 1898.

^ " Legons Cliniques sur les Maladies du Systemc Ncrveux."

3 Virohow's Archiv, bid. Ixxxvi., p. 421, 1881.

836 THE NERVOUS SYSTEM [ |

by repetition. In the treatment of some of these cases the author has
been very successful with systematised muscular exercises and deep
breathing.

Tio or Habit Spaim is a first cousin of chorea. It is, in fact, a localised choreifoni
movement, and it is often difficult to distinguish between tbe two discAaee. It pcacti-
oslly always starts in childhood, mostly in girls between seven and fourteen, ajxl it,
indeed, an exaggeration of the normal restlessness of this age. It consista of flndden
quick musctdar twitchings, say of the eyelids, face (causing grimaoee), shoulder, or
arm, differing from the chorea in (i.) being always limited to one place, (ii.) perfonning
the same action, and (iii.) running an indefinite course. The face and arma are the
most frequent situations, but the muscles of respiration or any other part may be
involved, and respiratory sniffs or grunts are not infrequent. It is alwa3rB worst when
the child is nervous, or attempts to restrain the movements, and parents should be
cautioned not to scold the child for the habit. There is frequently a history of neurostt
in the family, and habit spasm may certainly arise by the ** imitation ** of other childreo.
Arsenic is of considerable value, but other medicines are not of much use. Removal
from the surroundings under which the disease arose is the most efficient remedy.

A violent form of Impnliiye Tio allied to habit spasm, and, like it, mostly arisag
for the first time in children, though not confined to them, consists of explosive mus-
cular movements, usually of the face or arms, but in violent cases all over the body.
Explosive sounds accompany these movements, either barking or inarttoolate grants.
or the constant repetition of one word (echolalia), or some obscene or swearing
word (coprolalia) The condition often occurs in association with some im^ntal
deficiency.

Looalised Olonie Spasm may affect almost any voluntary muscle or group c^ musclei
in the body. The case should be investigated on the lines below indicated vnder
Facial Spasm. A large proportion are hysterical. In clonic spasm of the diapkrmgm
very curious respiratory spasms and grunts occur. Hysteria and possible reflex eause*
of irritation in the stomach should be remembered. It is also seen with organic oerebfsl
disease. Clonic masticatory spasms may arise in paralysis ag^tans and old age>. and
sometimes in hysteria. Nutatory or nodding spasms occur in children at the time 6L
dentition or as a form of epilepsy, sometimes, associated with nystagmus.

§ 694. Clonic Facial Spasm (Synon3rms : Spasmodic Tic, Convulsive Tic, Tic Kon-
douloureux. Mimic Spasm) is the term employed for a condition of persisteot clonic
spasm of the muscles of the face. Clonic facial spasm may arise under three difiierent
conditions : Oiganic lesion, reflex irritation and idiopathic or constitutional causes.
The favourite age for facial spasm is between thirty and sixty.

An organic lesion may give rise to facial spasm in the same way as it gives rise to
facial paralysis, and this cause is known either by the presence or a past history of
paralysis. However, if spasm be present, it is an indication either that the destruction
of the facial nerve tracts was incomplete, or else that partial recovery has taken place
(compare end of | 689). In this way tumours, such as sarcoma or aneurysm of the
vertebral artery, pressing on without entirely destroying the facial nerve, give rise to
facial spasm. A fall on the head or a cortical injury at birth may act similarly.
Diseases of the bones (syphilitic or tuberciilous) through which the nerve pasBco may
also be suspected ; and all the structures beside which the nerve passes should be
fully and thoroughly investigated. If the lesion be cerebral the spasm is more i
and is apt to involve muscles physiologically associated, perhaps on opposite
Thus, if both corrugators and the muscles on one cheek only be involved, a cortical
lesion is indicated. If it be the nucleus or the nerve trunk that is affected, we then
find that there are, or have been, the paresis and electrical changes characteristic ol
this condition.

Refitx irritation, especially of the fifth nerve, may be in operation. The teeth
should be examined, a history of injury to the fifth nerve inquired for. pharyngeal
adenoids removed, and the refraction should be tested.

Idiopathic Causes, such as grief or other emotion, debility, ansemia. the olimaotcfic,
hysteria, gout, rheumatism, syphilis, or tubercle, may act as contributory causes. It
is this group that belongs to the class Spasmodic Tio (mde supra).

!§ 995, 696] TORTIOOLLIS^POST-PARALTTIC SPASMS 837

Facial spasm of organic origin may be diagnosed from habit spasm by its persistence,
the age of the patient, the surroanding circumstances, and electrical changes (if any).
Bat I know of no means of distinguishing non-organic facial spasm from habit spasm
in the face, though all the books describe them separately.

Course and Treatment, — ^Facial spasm, as above described, is generally a very chronic
and progressive condition, resisting all our efforts excepting in those cases where the
cause is removable, and the causes should be thoroughly investigated on the lines
above given. Weak galvanism of the affected nerve may be tried. To palliate the
spasm bromides, gelsemium, cimicifuga, antipyrin, chloral, and in extreme cases
morphia and other nerve sedatives may be employed. Alcohol injections may be
tried, as in neuralgia. The nerve is destroyed, and on regeneration functions normally,
f 696. Torticollis (Wry-Neck) is a spasm of the muscles on one side of the neck.
Wry-neck is of two kinds — ^the congenital, due, probably, to injury at birth ; and the
acquired, which may appear at any age. In the former condition the spasm is tonic ;
in the latter the spasm is chiefly clonic, but in long-standing cases there may be some
tonic spasm as well, (a) Congenital wry-neck is due to a contraction of the stemo-
Biastoid of one side, rarely both. The chin is projected upwards and to the opposite
side. It may not be noticed by the parents till the child is several years old. It is
generally associated with facial asymmetry, as pointed out by Sir Samuel Wilks. The
only remedy is tenotomy. (&) Acquired torticollis consists of a slow clonic spasm
recurring every few minutes, associated in long-standing cases with a certain amount
of tonic spasm which, when the stemo-mastoid is involved (as is usual), draws the head
to the opposite side. In about half the oases the trapezius is associated in the spasm ;
in other cases the splenius, scalenus, and platysma may also be involved. The condition
is very intractable.

Causes (compare also the remarks on Facial Spasm, which apply here) and Treat-
ment,— ^The causes of torticollis are often obscure. The acquired form very commonly
appears to be of hysterical origin. I have mot with cases coming on after injury to
the back of the head, and in some cases relief has been obtained by remedying a gouty
or rheumatic habit of body. Like facial spasm {q.v.) wry-neck probably arises under
three different conditions — organic lesion, reflex irritation and idiopathic causes — and
treatment should be directed to these. Many drugs have been tried, without much
benefit. Galvanism of the spinal accessory nerve regularly applied twice daily has
in one instance produced permanent relief. Surgical means (stretching, division or
excision of the nerve, or division of the muscle and resection of the posterior branches
of the upper cervical nerves) have been tried, but as far as I am aware, without much
success.

Muscular twitchings or startings may arise in muscles which are over-fatigued or
in the half-waking state in various conditions attended by constitutional debility
{q.v,). They are an occasional symptom of neurasthenia, and twitchings of the same
idnd affecting the legs are also one of the earlier symptoms of peripheral neuritis.

f 696. Pofi-Paralytio Tremors and Spasms. — The fact that hemiplegia and para-
plegia of organic origin are gradually succeeded by tonic rigidity and other evidences
of lateral sclerosis has already been referred to, but occasioniJly we also get clonic
movements of various kinds supervening sooner or later, especially when the paralysis
has occurred in early life.^ There are many different Idnda of clonic spasm, but
practically they come under three types, which, in order of frequency, are (a) a slow
mobile spasm called atJutosis ; (b) movements which are more or less rhythmical ; and
(c) irregular choreiform movements not inappropriately called post-f^emiplegic chorea.
They are all characterised by (1) having the same distribution (generally hemiplegic)
as that of the preceding paralysis, though in cases of hemiplegia the arm is always
more affected than the leg. (2) The presence of the other symptoms of lateral sclerosis.
All of these movements are relatively rare in adults, but in such cases they are more
frequent after hemiplegia due to an embolic lesion than after a hemorrhagic one,
and also after lesions which are associated with hemiansasthesia. The jerkings of the
legs quite early in oases of paraplegia due to a complete transverse lesion with a fairly

1 This is one of the facts supporting the belief that tremors and clonic spasms of
organic origin are due to partial destruction or partial recovery of a motor nerve
tract. It is the recuperative power of childhood wnich leads to partial recovery.

838 THE NERVOUS SYSTEM [|

oxtensiTe area of hoalthy cord below, are caused, not by dosoending sclerosis. b«t, ss
most believe, by the cutting off of inhibitory influences from the brain.

The Prognosis of Tremors and Clonic Spasms in general terms is much more ^toot-
able than that of hemi- or para-plcgia — a fact which is in keeping with the remarks
on pathology in § 689. The prognosis of some has been dealt with in detaU. ( 1 ) In
none of the above conditions is there, as a rule, any immediate danger to life, exeeptang
in certain cases of chorea and paralytic dementia. (2) There are but three c^ the
above maladies which tend progressively to a lethal tennination — ^vix., disseminated
sclerosis, paralytic dementia, and progressive muscular atrophy. Disseminated
sclerosis lasts for an average of five or six years, being shortest in the cerebro-spinsl
form and longest in the spinal form, the cerebral form occupying an intermediate posi-
tion. In all four of these the course rarely lasts longer than ten years, and in aeute
cases only about a year or so. (3) Another group of the above dispiases endure for s
lifetime, though without materially shortening it — viz., paralysis agitans, senile tiraBor.
lateral sclerosis, many oases of facial and neck spasm, and some of the rarer group
allied to hysteria. Nevertheless, some of tiiese can be amdiorated. (4) Many of then
progress towards spontaneous recovery — eg., chorea, which is perhaps the most fre-
quent clonic spasm met with, h3rsterical and nervous tremors, habit spasm, and many
cases of facial spasm. (6) Many of the above are curable, chiefly by removing the
cause — for example, in alcoholic, metallic, and other toxic tremors, Qraves* Hisnssr
snd the great majority of those which depend on reflex and idiopathic eauaee.

Indications for the Treatment of Muscular Tremor and Spasm, — For the ratioBal
treatment the reader should refer to the brief reference to the pathology (ff 589 and
693), giving the three pathological causes on which the cases may depend. The
indications for treatment are fourfold. (1) To restore the partially damaged
fibres or otherwise remove the cause. Iodide of potassium is of use, not only in
of known syphilitic origin, to promote absorption, but also to eliminate toxic
such as lead, mercury, etc. (2) Careful investigation should always be made for
any reflex irritation, such, for instance, as any uterine, stomach, and oUier Tiaeeral
trouble in cases of hysterical spasm. (3) The third indication is to remedy any eon-
stitutional or general defect, such as ansBmia, rheumatism, debility, over-wofk. or
over-worry. (4) If the cause cannot be ascertained or eradicated, we oan, neverthe-
less, in many cases alleviate the tremor or spasm by appropriate means. Thns.
hyoscyamus and its alkaloid (hyoscine hydrobromide, gr. ^^ to ^ ter die) are wwrj
valuable in this respect, and many instances could be quoted of considerate rriiel in
cases of paralysis agitans, senile tremor, disseminated sclerosis, etc. Oannabis Indiea^
physostigma, conium (succus 58s. increased to 5bs.) may also be tried. Opium and
morphia are permissible in some severe oases, but, as a rule, the relief is only tempookry.
Bromides are undoubtedly of great value in neurasthenic and other nervous tremor^
hysterical tremors and spasms, paralytic dementia, and chorea. Warm baths, Turkish
baths, and the application of heat are agents for the relief of tremor and spasm whid
are too often neglected. Hot water internally and externally is the best remedy I know
of for the relief of spasm of unstriped muscular fibres (such as spasmodic dysmenor^
rhoaa) and the hot pack^ or hot bath, as mentioned before, acts wonderfully in oases
of chorea. The very simplicity of this remedy — ^the application of heat — renders it
all the more valuable. In oases where the paralysis is a leading feature strychnine may
be given, though, as a rule, this remedy is contra-indicated in nearly all olonio spmamm.
Tremors and spasms of hysterical origin must be treated on geneitd lines, as in otber
cases. Gold douches are useful for functional spasms. Localised muscular spasms are
also treated by massage and electricity, the anodal pole being placed on the affected

The patient has attacks of clonic and tonic spasniB associated wiik fmort
or less DISTURBANCE OF CONSCIOUSNESS. The case is one of Convulsions.

^ A thick blanket should be thoroughly wetted in a pail of boiling wator. wrung out.
and rolled up tight, and then the patient rolled in it, afterwards in another dry one,
and left for half an hour to perspire. It is often advisable to promote diaphoresis by
a dose of liquor ammonisB acetatis, for the benefit derivable is much loss unless per^
spiration ensues.

H 597. 608] OONVULSIONS 839

§607* OonviilsiCMUl are sudden, violent, clonic, and sometimes tonic
spasms affecting the greater part or the whole of the body, usually accom-
panied by some disturbance of consciousness.

The most conmion cause of convulsions is idiopathic epilepsy, and con-
vulsions arising from other causes may so closely resemble epilepsy that
fhey are often described as epileptiform convulsions. Eclampsia is a
term formerly used for epileptiform convulsions. The following are the
causes of convulsions :

Functional,
I. IdiopAthio epilepsy.
II. Hysterioal oonvulsionB.

Organic Lesions,
in. Intracranial Byphilis.
IV. Gross lesions of an irritative nature, suoh as (1) intracranial tumour (Jack-

sonian epilepsy) ; (2) hemorrhage and embolism ; (3) chronic degenerations

of the nervous system ; (4) acute meningitis.

Toxic Causes,

y. UrsBmia, diabetes, cholamia.
yi. Puerperal eclampsia.

VII. Various other toz»mic conditions, such as (1) alcohol ; (2) lead ; (3) drugs ;
(4) tetanus (tonic spasm), diabetes, malaria, acute specific fevers (in chil-
dren).

Circulatory,

VIII. Gardio- vascular disorders, including chronic Bright's disease.

Be/lex,
IX. Reflex causes.

Contfulsions in Infancy and ChUdhood,

The chief points in the glinioal iNVBSTiaATiON of a convulsive attack are the age
of the patient, the character of the attack, the state immediately preceding and follow-
ing it, and the attendant conditions. Ask first the age, and secondly whether the
patient ever had an attack before. If the patient be under twelve months old, turn
to Infantile Convulsions (§ 699). Between one and ten years of age embolism, hemor-
rhage, and many constitutional derangements may give rise to convulsions. Between
ten and twenty is the commonest time for idiopathic epilepsy to commence. If the
patient be over thirty, and has never had a fit before, syphilis should be suspected.
Hysterical convulsions mostly affect the female sex between fifteen and twenty-five
and at the climacteric. If the patient be over fifty, ursamia and apoplexy should be
suspected. Thirdly, the cJiaracters of the fit afford considerable aid in diagnosis. Thus
(i.) the convulsions of major epilepsy and major hysteria are always generalised ;
partial convulsions indicate usually a cortical lesion (Jacksonian epilepsy), (ii.) Un-
consciousness is an invariable accompaniment of epilepsy, and is very usual with
urssmia, cerebral haemorrhage, and syphilis. On the other hand, consciousness is not
completely obliterated in by far the greater number of cases of hysterical convulsions,
and in a considerable number of limited cortical lesions. Fourthly, inquiry should be
made as to whether the fit was preceded by an aura (epilepsy), and what is the condi-
tion immediately afterwards. Fifthly, the history and attendant symptoms shoiild be
examined in the usual way. The presence of a blue line on the gums or cutaneous
syphilitic lesions may decide the diagnosis of lead poisoning or syphilis. Lumbar
puncture gives assistance in some cases.

§ 608* Idiopaihic Eidlepsy (SynouTm : Falling Sickn^^s) is a disease
which consists of sudden attacks of loss of consciousness, with or without

840 THE NERVOUS 878TBM [ I M

convulsions, without any discoverable lesion in the blood or in the brain.
It occurs in two clinical forms, minor epilepsy (petit mal), which consbts
simply of a transitory disturbance of consciousness, and is therefore referred
to in § 529, and major epilepsy (haut mal, grand mal), which consistB of a
convulsive seizure with loss of consciousness.

Symptoms, — A complete epileptic fit has the following characters, though
they are rarely all present in their entirety : (1) In some cases, dnring the
previous twelve to twenty-four hours, there may be prodromata, (x>nsisting
of headache, giddiness, malaise, or alteration of character or mood. In
more than half the cases this stage is absent. (2) The fit in many caaes
is immediately preceded by an aura or warning — i.e., a sensation lasting
art most only a few seconds, which is of value as indicating the point of
the cortex whence the cortical nerve-storm starts. Of these anrae there
are four groups. Sensory aurce are most common — e.g., " a wave passing
over the body," numbness, flashes of light or of colour, or singing in the
cars ; motor aurce — e.g., twitching of a diuscle or a limb, rarely of the trunk,
and in rare cases there is a " procursive aura," in which the patient runs .
forward or turns round and round ; psychical aurcs — e.g., various strange
thoughts or perhaps illusions ; and, somatic aurcs — e.g., gastric discomfort,
nausea, or fluttering in the stomach. Some form of aura is present, in
my experience, in about three-quarters of the cases. (3) Loss of conscious-
ness is the pathognomonic and indispensable feature of all forms of idio>
pathic epilepsy. It succeeds the aura so quickly that the patient may not
have time to place himself out of danger before loss of consciousnem is
complete. (4) Convulsions supervene almost at the same time as the un-
consciousness. They are often ushered in with a scream, and in the
classical form consist of a short stage of tonic convulsions lasting about
forty seconds, followed by a stage of clonic convulsions lasting one to three
minutes. In the tonic stage the breath is held, the hands clenched, the
back rigid, the legs extended, the pulse quick and may be imperceptible.
During the tonic stage respiration is stopped, and the patient becomes
blue in the face (a diagnostic point of value). The clonic movements soon
involve the whole body, and are sometimes of great violence, consisting
of rapid extension and flexion of the limbs, opening and shutting of eyes
and jaws. The tongue is often bitten — ^a danger to avoid by thrusting a
piece of wood, the handle of a pocket-knife, or something of the kind be-
tween the jaws. The pupils are dilated and the conjunctiva insensitive.
As the convulsions pass oft the respiration becomes stertorous or snoring.
Urine, faeces, and even semen may be voided. The saliva issues from
the mouth as a frothy foam, sometimes blood-stained from injury of the
tongue. (5) A stage of stupor or drowsirbess succeeds the convulsions, and
may last for some hours. This stage passes gradually into a deep sleep.
The temperature directly after the convulsions is said to be raised, some-
times as much as 4° or 5° F. (6) In the post-epileptic state, after recovery,
there may be aphasia, or transient paresis, or the patient may perform
automatic, irresponsible acts, dressing or undressing himself, or putting

S 608 ] IDIOPATHIC EPILEP8 7 841

the property of others into his own pocket. Occasionally hallucinations,
delusions, or active mania ensue, or the patient makes obscene remarks
or commits acts of violence. Some patients are distinctly homicidal,
rarely suicidal. One fact of considerable forensic import must be men-
tioned— ^namely, the phenomena of the post-epileptic state are by no means
proportionate to the severity of the seizure (major or minor) which they
follow — often quite the reverse. After severe fits the patient is exhausted,
after slighter attacks his faculties are often stimulated, and he may perform
acts of which afterwards he has no recollection.

The intervals between the fits vary considerably ; any time from a few
days to many years. In the intervals the patient usually remains in fairly
good health of mind and body until the next attack ; indeed, it frequently
happens that he professes himself in better health after an attack than
before. Epilepsy has a close association with insanity. In a certain
proportion of fits the cases are followed by weakmindedness, whether the
case has been treated with bromides or not ; occasionally by other forms
of insanity. It appears to be the frequency, rather than the severity, of
the fits, the age at which they commenced, and the heredity that determine
the occurrence of mental alteration. Thus, petit mal quite as often leads
to mental trouble as does epilepsy major ; some say more often. Again,
epileptic fits may be followed (and sometimes even replaced) by mania of a
a most dangerous nature, in which the patient may (quite unconsciously)
commit acts of the most brutal kind. Epilepsy and insanity appear to
be closely related to each other by their hereditary origin ; one child may
be epileptic, another insane.

Varieties, — The above is the classical form of epilepsy major, but every
degree of severity may be found between this and epilepsy minor. Fre-
quently one or the other, or several of the above features may be wanting,
but unconsciousness is the one constant feature, and in epilepsy minor it
may be the only symptom preset. Sometimes fits of various kinds may
alternate in the same patient ; but generally each patient has fits which
conform to one, or at most to two, varieties. The stattis epUeptious is a
rare condition in which the patient has a series of fits occurring in very
rapid succession for several hours or even days, consciousness not being
regained in the intervals ; the temperature may rise to 107^ F., and the
condition may be fatal.

The Diagnosis of epilepsy minor will be found in § 529. Epilepsy major
may have to be diagnosed from any of the causes of convulsions (see list,
§ 597 ; see also table below). Convulsions coming on for the first time
after thirty are more probably syphilitic than idiopathic. In feigned
epilepsy the pupils are not dilated, and they react normally to light, the
conjunctivae are sensitive, and the application of strong ammonia to the
nostrils generally reveals the fraud ; the absence of the cyanotic condition
may also aid. The alleged fact that the patient will not hurt himself is not
of very great assistance, for I have often seen patients do themselves injury
if the motive for the fraud is sufficiently powerful.

842

THE NERVOUS SYSTEM

Course and Prognosis. — If unchecked by treatment the fits recur through-
out life, though with widely varying frequency. The frequency of the
fits is the leading factor in the prognosis. Those in whom fits occur with
moderate severity a few times per annum may remain well and clever,
but when more frequent mental deterioration results, not, be it reman-
bered, as a consequence of the administration of bromide, but as a part of
the disease. Indeed, in petit mal, on which bromide has least influence,
mental symptoms ensue more often than in grand mal. A combiBation
of the two forms is worse than either singly. Death may occur from an
accident during the fit, but rarely or never from the disease.

Table of Diagnosis of Epilbpst.

Major BpUepty.

Hytterieal OonpuUiom,

Feigns Epa^pm-

Preceded by

Charaoterifltio aura.

Globus, or cboUng,
epigastric sinking
or emotional dis-
tarbanoe.

A moUve for ftesd.

Mode of onset

Sudden ; lometiines

Somettmes gradual.

CmeMhr pimmnti

with one tyirtcal

perhaps with

cry.
March definite and

screams.
Progress irregular.

Charaoten of oon-

Not foUowfag tbe

▼ulsions.

noiseletf.

with screaming or

usual mneli: mk-

Tonic brief, followed

orjflng.

Btmes of <VMMsif

by donio move-

Tonic rigidity often

mnd mtphpsim;

menta.

prolonged and re-

urine and teoss

Cyanoiia daring tonic

current.

not voided; tongue

stage ; tongue may

Clonic movements

notbittea.

be bitten ; nrine

often purposive

and f secee may be

and irregular;

Toided.

Umgtu not bittm;
urine and f»oes
rarely voided ; usu-

ally no cyanosis.

ComoiousiieaB.

Always lost.

Never quite lost.

Retained.

Eye Bsrmptoms.

Pupils dilated and

Pupils responsive to

Confunetiwm mmti-

irresponsive to

light; conjunctive

Um ; pMpHa r«-

light; conJonotiviB

sensitive.

tpontim to UfU.

insensitive.
Barely exceeds a few

Duration.

Generally exceeds 4

Indefinite.

minutes.

or 5 minutes, may
last half an hour,

and liable to recur.

Termination.

Stupor and drowsi-

Sobbing, crying.

Not followed by pro-

ness.

laughter, or pros-

found stupor.

tration.

Etiology. — Both sexes are about equally a£Eected. About 75 per cent.
start the fits before the age of fourteen ; idiopathic epilepsy very rarely
b^ins after twenty. Heredity b a potent factor, and in a large proportion
there is a family history of epilepsy or other nervous ailments. Among
the determining causes of a fit may be mentioned fright, excitement, head
injuries, the menstrual period (many females have fits only at that timeX

§ 618 ] IDIOPATHIC EPILEP8 Y 843

alcoholic and sexual excess. Epileptic fits have been known to be asso-
ciated reflexly with such canses as the. irritation of a scar, disease of the
eyeball, disease of the nasal mucous membrane, on the removal of which
the fits ceased. It has been shown, moreover, that in certain epi-
leptics having a high degree of asthenopia, the fits become much less fre-
quent or cease altogether when the error of refraction is accurately corrected
and the asthenopia relieved.

It is worthy of note that Haghlings Jackson^ believed that every epileptic patient
had an epileptiginons zone or area, corresponding on the surface of the body to the
centre in the brain whence the cortical discharge starts ; but in actual practice it is
rarely possible to discover this zone.'

Tl^ee oases are recorded^ in whom, in addition to fits occurring spontaneously
in the usual way, slight cutaneous irritation in a definite area produced an epileptic
seizure. In Dr. Jackson's case a boy aged eight, a flick with a silk handkerchief on
the back of the head from behind, so that he received no warning, would result in
his immediately falling down in a fit. In 1897, at the age of nineteen, this boy was
under my care, and he presented hemiplegia and unmistakable signs of descending
sclerosis and commencing athetosis. It is extremely interesting to notice that all
these cases presented important features in common. All were children — ^two boys
and one girl — and in all the fits began early in life. In all the epileptiginous zone
was situated in the head, and it was only when the patients were unaware that they
were going to be touched that fits were produced. In falling, it was noticed that
these patients generally struck their heads with great violence, suggesting that the
olonio convulsions began in the neck muscles, pulling down the head in one direction.
Finally, there were evidences in all pointing to a gross lesion of the brain as a cause
of the fits. The two boys were hemiplegic, and this symptom was increased after
the fits. The girl was not hemiplegic, but in her the history of a series of convulsions
at the age of three, followed by two years' interval, points in the same direction (see
f 599 below).

Treatment. — Bromides constitute the sheet-anchor in the treatment of

idiopathic epilepsy. Personally I prefer the anmionium salt in doses of

20 grains twice daily, gradually increased to 60 grains until the fits cease

to occur. The administration should continue for two full years after'

the palate reflex is lost. For nocturnal epilepsy add digitalis to a single

dose of bromide. If bromides fail, borax, belladonna, picrotoxin (or a

combination of this with bromide, known as Glelinot's drag6es), amyl

nitrite or liquor trinitrini three or four times a day may ward ofE an

attack of E. major, but the two last aggravate E. minor. Morphia has

been successful where other things failed. A regular life aids ; and excess

of animal food (of which these patients are Very fond), and of salt, should

be avoided. Regular purgation is of distinct advantage in many cases.

Possible causes of reflex irritation should be removed. The treatment

during an attack consists simply in placing something between the teeth

and preventing injury. The status epilepticus may be ameliorated by

amyl nitrite, chloroform, chloral hydrate by rectum, morphia, and ice to

the spine.

Hjiterical Oonvnlsions constitute 18*5 per cent. (Gowers) of cases of convulsions.
They form a frequent manifestation of hysteria, occurring in my experience in about

* Med. Soc. Trans. * Qowers, " Diseases of the Nervous System."

3 James Dunsmure, Edinburgh Med. Joum., October, 1874 ; Hughlings Jackson,
BriL Med. Jaum., 1886, u., p. 962 ; Wilfred J. Harris. Lancet, 1897, u., p. 637.

844 THE NEBV0U8 8J8TBM [ |

30 per cent, of the oases. The oonvnlsions are irregular, but consist of tonic
sometimes amounting to opisthotonos; aUenuUing with clonic spasms, often accom-
panied by screaming, lasting longer than true epilepsy, and usually with purpoaTv
movements, such as dashing the head against a pillow, throwing Uie anna about, and
struggling with those restraining her. The patient may then have a sucoeeaion d
fits for a few hours. The severer form described by Charcot, Richer, and othen m
hystero-epilepsy consists of four stages — tonic and clonic spasms, emotional attitwk^,
and delirium. Trance or lethargy may follow and last for days. The diagnotik
features of a hysterical from an epileptic fit are : (1) The onset dates from some
emotional disturbance, and it is not preceded by a definite aura, though it is frequently
preceded by the globus or an epigastric sinking. (2) The convulsions do not foUov
the regular order of epilepsy ; there is more tonic rigidity throughout, and many of
the clonic movements have a distinctly purposive character. (3) The oonsciouaDiMi
is very rarely lost ; the conjunotivaa are sensitive, and the patient may be talking
nonsense all the time (which never occurs in epilepsy), though she may not afterwards
remember who was there. The urine and fcsces are not voided. On reoovering, the
patient may burst into tears or laughter.

HyskrO'EpUepsy, as described by Charcot and Paul Richer is very rare in Kngland.
In all my experience at the Paddington Infirmary I only saw three cases like those I
saw in France. One of thess was a man aged twenty-nine, whoso attacks were ol
great violence, and consisted of four stages : (1) a tonic, (2) a clonic. (3) a stage of
purposive movements, and (4) a stage of incoherent delirium.^ Another was a womao
who had many fits in series of such violence that it took four people to preveat ber
harming hersdf and others, until I discovered that a hypodermio of apomorphine and
copious emosis cut them short.

Intraoranial Ssrphilis is the most frequent cause of convulsive fits oocur-
ring for the first time over twenty-five years of age. Convulsions are,
moreover, a very frequent manifestation of cerebral syphilis (Charcot and
others). Sometimes the convulsions are due to a gumma, sometimes to
meningeal thickening, sometimes to a difEuse meningitis, but occasionally
no gross changes are found beyond congestion of the cortex. In gum-
matous cases the convulsions have Jacksonian characters (see below),
but in other cases the fits are indistinguishable from idiopathic epilepsy
excepting by attendant circumstances — ^namely (1) the age of onset (over
twenty-five) ; (2) severe headache, which is present in over 77 per cent.
of the cases and heralds the attack — continuous, bilateral, markedly worse
at night, and getting progressively worse up to the attack. Pains in the
limbs may also be present. (3) There is more often mental hebetude
between the fits. (4) If the lesion be gummatous there may be scattered
lesions of the cranial nerves, and especially optic neuritis, or partial
transient palsies or transient aphasia. (5) A history of primary or secon-
dary syphilis.

Irritatiye Laitoni of the Cerebral Oortez are always attended by convulsioas.

(1) Jacksonian Epilepsy may be caused by a syphilitic gumma or other ttunoar. or
a cicatrix in the brain after operation, injury, or h»morrhage. occupying the coHex
on the motor area (Fig. 146). (i.) When a lesion irritates one of the motor anmm of
the cortex, the clonic spasms are always partial — at any rate, at the outset, the
convulsions starting in, and aometimea limited to, the fingers or toes, one forearm or
log. or the face on one side. The point of starting indicates the precise position of
the lesion in the cortex. The clonic spasms may remain limited, or may grraduaOy
spread to the rest of the body, (ii.) There is no loss of consciousness, unless the move-
monts become general and violent, (iii.) The attacks are apt to follow in freqiBent

* Clin. Soc. Trans.. 1889.

§5W] JACKSONIAN EPILEPSY 845

8iiooe68ion in a series, (iv.) There is no aura ; as a matter of faot, the twitching of
the thumb or big toe, as the case may be, constitutes a motor aura, and is known as
the " signal symptom."

(2) H»morrhage and EmboUim of the brain are attended by a generalised epilepti-
form seizure in about half the cases. They are more frequent in hiemorrhage than
in embolism, but this fact has not the value for purposes of diagnosis, which was
attributed to it by the older authors. The convulsions under these circumstances
usually predominate on one side, are at first attended by tonic spasm, and later by
paralysis on the side opposite to the lesion. The age and history also aid in the
diagnosis. Mitral stenosis favours the diagnosis of embolism.

(3) Various Ohronio Degeneratioiii of the nervous system are sometimes attended
by generalised convulsions. The most frequent, perhaps, of these is general paralysis
of the insane, especially in the congestive form. They are comparatively rare in
disseminated sclerosis.

(4) Acute Meningitis (at the outset) and Hydrocephalfas in children, and Paohy-
meningitii in the adult are frequently attended by generalised convulsions, but these
have not Jacksonian characters. They are said to be relatively infrequent in alco-
holic meningitis and cerebral abscess (Gowers).

nr«mio Oonvulsionf are associated with renal disease, especially the chronic inter-
stitial form. Convulsions, especially if associated or alternating with coma, occurring
suddenly for the first time in a person over fifty years of age, offer a presumption
of ursemia or apoplexy. Ursemia is distinguished from apoplexy by (1) the absence
of hemiplegia and the pupillary reactions (f 530) ; (2) an examination of the urino
reveals renal disease. Finally, it should be remembered that apoplexy and uremic
convulsions may be present at the same time.

Puerperal Eelampiia (Synonym : Puerperal Convulsions) is the term applied to
convulsions occurring before, during, or after labour, and they only differ from
idiopathic epilepsy in the circumstances under which they occur. They are practi-
cally always associated with albuminuria, and are in all probability of toxsemic origin.
They may be associated throughout with some rise of temperature. Bleeding and
the tran^usion of normal saline fluid (§ 406) have been warmly advocated. Chloro-
form and chloral are very useful.

Various other tox»mio conditions may be attended by epileptiform convulsions
subh as (1) ALCOHOLISM, especially in a chronic alcoholic after a drunken orgio.
(2) Lkad PoisoNiNa occasionally, when other symptoms of plumbism would bo
present. (3) Various dbuqs given in overdose or attempted poisoning — strychnine
(when the convulsions are mainly tonic), belladonna, strophanthus, stramonium,
aconite, veratrium viride, sabadilla, hydrocyanic acid, in all of which the convulsions
come on suddenly, other symptoms of the drug are present, and the case terminates
one way or the other in twenty-four hours. (4) Tetanus (in which the spasms are
chiefly tonic), and malaria in adults, and the onset of the acutb specifio fevers
in children. (5) Convulsions also occur with diabetes and with jaundice in the
terminal stages of diseases of the liver, such as acute yellow atrophy.

Oardio-Vasoular Disorders give rise to epileptiform seizures in adult and advanced
life more frequently than is generally supposed. Kussmaul has shown experimentally^
that either anaemia or congestion of the brain may produce convulsions, and we
know that profuse haemorrhage in cut throat cases and cases of asphyxia may be
so attended. This explains their occurrence in cardiac weakness, especially when
associated with vascular disease in the aged, and in congenital heart disease in youth.
Stokes-Adams Disease, which illustrates the same principle, has been described in
§ 59. It is characterised by a permanently slow pulse, with syncopal and epileptiform
attacks. The fits may occur in succession and be indistingmshable from epilepsy
excepting by the age of onset, the slow pulse, and the cardiac condition. Sometimes
the attack resembles syncope, and is more transient.

Reflex Oaosei occasionally produce epileptiform convulsions. In addition to those
already mentioned under the etiology of idiopathic epilepsy it may be remembered
that washing out the pleural cavity after aspiration and severe renaJ and biliary colic

^ Publications of the New Sydenham Society.

846 THE NEBV0U8 SYSTEM [KSMlM

are oooasionaUy followed by oonvulsioxis. Intestinal parasites, a ti^t prepoee,
and any ohronio peripheral irritation may cause oonvulsions in childhood («e
below).

§ 599. Gonvulrioiis in Infancy and Childhood may be produced by some
of the foregoing conditions, but owing to the susceptibility of the nervous
system in childhood, other and slighter causes may also produce conviil-
sions. Judging by the frequency with which slight causes are followed by
convulsions in children, it seems as though the instability of the cortical
motor cells, which constitutes the essential disorder in idiopathic epilepsy,
exists as a normal condition in infancy.

(1) Blood Poisons, — ^The acute eraptive fevers in adult life may be ushered in by a
general tremor (rigor), but in childhood their advent is frequently marked by genenl-
ised convulsions. The advent of infantile {laralysis, acute pneumonia, and maoj
other acute diseases might also be mentioned. Rickets is often accompanied by
convulsions, probably due to gastro-intestinal tozsomia. BaoiHuria is a cause usnaDy
overlooked. (2) Reflex Causes, — Oonstipation, worms, or any other irritative condi-
tion of the alimentary canal, teething, and the like, are frequently attended by cob-
vulsions caused either in a reflex or toxic manner. (3) Gross Lesions of the Braim,
such as injuries to the brain at birth, hydrocephalus, tumours, absoess following otitis
media, and some of the other gross conditions above named. Meningitis should
be suspected if there is retraction of the head, peevishness on movement, or squint.
Many of the causes of tetany, trismus, aad carpo-podal contractions, may also give
rise to convulsions. (4) In childron under ten Cerebral Husmorrkage may occur, with
convulsions, usually followed by hemiplegia (§ 555). In children a smaU oorticsl
hemorrhage or embolism may occur without a definite or very noticeable hemiplegia,
and i» few years later the cicatrix may be sufficient to cause recurring fits practioaUy
identical with idiopathic epilepsy. When fits have commenced under ten yean ol
age, careful inquiry should be made of the mother as to whether any hemiplegia
accompanied or preceded the first fit. It has been estimated that in about one-half
of these cases the convulsive seizures date from the occurrence of the hasmonhage ;
but in the other half they do not commence until some time afterwards. In some
cases convulsive attacks preceded by an aura and indistinguishable from idiopathic
epilepsy may continue at intervals throughout life, but in other cases the clonic spasms
are unilateral or Jacksonian in character (see also cases referred to on p. 843. amU),

On the whole, the Prognosis of infantile oonvulsions is much more ^voursble than
the same symptom in adults, a statement which follows from the opening coosideia-
tions. In the Treatment attention should always be first paid to the intestinal canal.
which is so easily upset in children, and as a general rule the administration of castor
oil and lime water in equal parts, a teaspoonful every four hours, is a good adjunct to
other measures of treatment. Hyd. cum cret.. magnesia, and soda are also uaefiiL
The cause in nine cases out of ten wiU be thus relieved, but careful inquiry should
be made for other possibilities. To relieve the convulsions, bromide, preferably of
ammonium, in 1 to 10 grain doses, is very useful, and it may be given with ^ to 2 grains
of chloral. In severe cases chloroform may be administered, and a very little ii
sufficient to relieve the spasms.

S. Muscular Atrophy.

§ 600. Muscular wasting occurs in two groups of disorders : (1) Tlio^
due to a lesion of some part of the lower motor neuron (the peripheral
nerves or their cells of origin in the anterior horns of the ^inal cord),
when it is spoken of as atrophic or amyotrophic paralysis, or briefly ms
amyotrophy; (2) those due to a lesion in the muscle itself, when it a
spoken of as myopathy, or idiopathic myopathy.

1601]

MU80DLAM ATBOPUY

847

At least thirteen olinical types of amyotrophy have been described,
some with very little real difference, and these may be classified into four
fairly marked clinical and anatomical groupd.

Anterior
horns of
spinal
cord.

a. Amyotrophies ttnthaut Sensory Changes.
I. Aoute anterior poliomyelitis Flaccid atrophic paralysis, with

B. D. No sensory changes and
no pain after onset.

Nerve
trunks.

(rare in adults).
II. Acute and subacute anterior
poliomyelitis of adults.

III. Progressive muscular <

atrophy (rare in ohil- i
dren).
Amyotrophic lateral

IV. • sclerosis.

Bulbar paralysis.
y. Progressive spinal muscular
atrophy of infants.

h. Amyotrophies with Pain and Sensory Changes,

VL Plexus paralysis. Flaccid atrophic paralysis with

VII. Localised neuritis. pain and sensory changes.

VIII. Multiple neuritis. R. D. present.

Muscles
only.

c. Myopathies.

IX. Myopathy, with loss of
volume :

Duchenno's infantile ,

myopathy.
Erb's juvenile my-
opathy.
X. Pseudo-hypertrophic pa-
ralysis.
XI. Peroneal type (doubtful
whether muscular or '
neuro-musoular). i

XII. Amyotonia congenita.

Simple muscular weakness, with
loss of volume, predominating
in one or other place. No pain.
No sensory changes. No K. D.

Same as preceding, but with in-
crease of volume.

May also have slight sensory
changes and fibrillary twitch-
ings.

d. Reflex Amyotrophy.
I XIII. Arthritic atrophy. | Extensor amyotrophic paralysis.

In the Clinical Invbstigation there are aeveral important fallacies to be borne
in mind. In the first place the amy:, trophies must not be confused with the general
wasting due to constitutional debility (Chapter XVI.). (2) They must not be con-
fused with the different forms of upper neuron paralysis, which, when of long standing,
are sometimes followed by a slight degree of wasting from disuse ; or (3) the wasting
consequent on disuse after the application of Sayre's jackets or other apparatus.

The Clinical Features to investigate are (1) the flaccidity of the paralysis, the
absence of the knee-jerks, and the electrical alterations, which are the three features
(in addition to atrophy) which distinguish lower neuron paralyses. (2) The distribu-
tion of the amyotrophy. (3) The presence of sensory alterations is of value to localise
a lesion. (4) The mode of onset of the disease ; and (6) the age of the patient are
also important.

§ 001. Acute Anterior Poliomyelitis (Synonyms : Poliomyelitis, Infantile
Paralysis, Atrophic Spinal Paralysis) may be defined as a disease of in-
fancy, coming on suddenly with feverishness, characterised by rapid
-wasting and loss of power in one or more groups of muscles, due to inflan^-

848 TEE NEMVOUa SYSTEM [ § M

mation of the anterior comua mostlj locate in the lumbar or cervical
enlargements. CSinicallj the malady resembles an acute infection, and
epidemics occur. Flexner's recent researches tend to prove that the
disease is due to a virus which can pass through a filter.

Symptoms. — (1) The patient is usually about the age of the first denti-
tion, very rarely older than fourteen years. The advent is sudd^i, and
is ushered in by moderate pyrexia (like an acute specific fever), geneial
prostration, and more rarely by convulsions. The fever lasts a few days«
Fains in the limbs may be complained of at the outset, and may form a
prominent feature. Or there may be no fever ; the child wakes up, and
is found to have paralysis. In tiie epidemic type the fever lasts longer,
and there may be at the outset delirium, stupor, and retraction of the
head, and sometimes loss of sphincter control. (2) Sometimes the paralysis
attacks only one limb, sometimes all four ; and it not infrequently takes
the form of paraplegia. At first (in the course of twenty-four to forty-
eight hours) all the muscles of the limb or limbs are affected with flaccid
paralysis and rapid wasting, and they are tender to touch or movement.
In a few weeks some of the muscles begin to recover, while tiie otheEs
undergo progressive wasting. All the affected muscles show the reaction
of degeneration as early as a week after the attack. (3) The superficial
and deep reflexes are abolished in the paralysed parts; the knee-jerk
remains lost only when the quadriceps b permanently paralysed. (4) There
is absolutely no affection of sensation. The bladder and rectum are not
infrequently affected, but there is no tendency to bedsores. (5) In the
course of a few months the amyotrophy settles down into a muscle or
group of muscles — ^for instance, in the leg the tibialis anticus or quadriceps
(more rarely the hamstrings or glutei), and in the arm the deltoid, brachialiB,
or supinator longus. These muscles atrophy, degenerate, and finally, a
year or so later, undergo contraction, producing various characteristic
and familiar deformities (club-foot, etc.). Some hold that the deformities
are due to contracture of tbe atrophied muscles ; and some that they are
due to neurotrophic changes in the joints and ligaments ; but the unop-
posed contraction (which is constant) of the imaffected muscles has always
appeared to me sufficient, bearing in mind the age-period at which the
disease occurs. The affected limb becomes blue and cold, and the bones
do not grow so much as on the healthy side. It seems probable from this
that the anterior comual cells control the tone of the involuntary as well
as the volimtary muscles of the part.

Diagnosis, — The disease is practically confined to early childhood. At
the onset the malady is mostly mistaken for a *' chill," or the onset of an
acute specific fever. In the pseudo-paralysis of rickets there is no atrophy.
In meningecd affections the spinal pain is very marked, and the muscular
atrophy is not so pronounced. Peripheral neuriHs has more pain and
does not produce such a rapid or localised amyotrophy. In old-standing
cases the history of acute onset differentiates it from idiopathic myopathy.
Syphilitic pseudo-paralysis due to separation of the cartilage at the

$ eOl ] AOUfE ANTERIOR POLIOMYELITIS d49

of the diaphysis has orepitation and pain on movement. In infantile
scurvy theie is tenderness and swelling of the affected limbs. Recently
(1911) epidemics of cerebrospinal meningitis and of acute anterior polio-
myelitis have drawn attention to the points of diagnosis between the two
conditions. In both there may be sadden onset with fever, retraction of
the head, and stupor ; but in cerebro-spinal meningitis there is muscular
spasm ; in poliomyelitis there is flaccid paralysis. Limibar puncture reveals
characteristic differences (§ 626).

Prognosis. — The disease is not fatal in itself, but complete recovery is
rare. Within a few weeks or months after the acute disturbance has sub-
sided, the muscles may usually be grouped into three groups : (a) Those
which will recover of themselves, and in these the electrical changes are
but little altered. (6) Those which may recover imder treatment. In
these the galvanic changes are typical — i.e., increased, with A.C.C.>K.C.C.,
and the faradic reaction is not quite lost, (c) Those which probably will
not recover under any treatment, and in these faradism gives no response
whatever. Death may occur from pneimionia or otJier intercurrent
diseases.

Etiology. — The disease occurs chiefly in children under ten, usually
about the age of one, two, or three years. It only occasionally affects
adults. Chill has been supposed to cause it ; and it has appeared during
convalescence from acute diseases. It is more frequent in sunmier, and
has occurred in epidemics. During epidemics adults may be affected, and
abortive cases occur without paralysis. Its clinical course resembles an
acute microbic disease, which results in destruction of certain groups of
multipolar cells in the spinal cord. The virus is suspected to be conveyed
in the mucosa of the naso-pharynx by healthy carriers.

Treatment, — ^At first rest in bed, salines, and diaphoretics are ordered,
with anodynes if there be much restlessness. The patient should be iso-
lated, and secretion from the naso-pharynx disinfected and destroyed.
Urotropine should be given in full doses, as it has been experimentally
found to be antagonistic to the virus. After the acute stage treatment
should be begun for the paralysed muscles. For these the galvano-faradic
current, or ^e galvanic current alone, followed by massage and sham-
pooing form undoubtedly the most efficacious treatment. Electricity or
massage alone is not nearly so valuable. It is generally held that no
treatment is of any use after a few years have elapsed, but I have obtained
considerable benefit in patients even twenty and twenty-five years later.
The treatment of the deformities which result is surgical, but they may
be prevented by guarding against contraction.

Acnte and Snbaoute Poliomyelitii in adults (Synonym : Atrophio Spinal Paralysis
of Adoits) is almost the counterpart of infantile paralysis, ooourring between twenty-
five and thirty years old. It commences with fever and pains in the back, which may
last a week or two, accompanied or followed by paralysis, frequently of both arms
and legs. In the subacute form one group of muscles after another may become
paraljrsed till the whole body is affected. The disease is frequently mistaken for
multiple neuritis (§ 561), in which, however, pain in the limbs is a prominent feature.

862 THE NERVOVa SYSTEM [f

Landouzy-D^j^rme type, (ill.) Form beginning in the legs (rare). In most idiopathic
myopathies the muscular wasting begins and predominates in the biceps, trioept, And
supinator longus, and the shoulder muscles, the latissimus dorsi, teres major, aod
lower two-thirds of the pectoralis major. The hands are rarely involyed. In ti»
Landouzy-IMj^rine type the face muscles are first attacked ; the nasolabial fold is
lost, the lips are apart, the lower lip projecting, and a peculiar dull expression is
present. In a good many cases first noticc^l in adolescence or later there is a history
of the patient being unable to close the eyelids properly from earliest childhood.

Psendo-Hypertrophio Paralysis, or Dnchenne's Paralysis (Fig. 5. § 16), is the only
form of idiopathic myopathy in which there is an increased volume in the musdes,
and this is due to an increase in the interstitial tissue. The clinical features by which
it may be recognised are : (1) The patient is always a child, the disease haYing beoi
first noticed between the ages of four and fourteen, and he is generally brought to us
for " weakness of the legs.'* (ii) On account of the disease predominating in the legi.
the walk is a waddle, and very characteristic, and when the patient lies down he is
unable to get up without clambering up by placing his hands on his own knees,
(iii.) There is a notable increase in the volume of some of the muscles, espccdally of
the calves and buttocks, which gives the ohUd the appearance of an infant Hercules.
The muscles in pseudo-hypcrtrophic paralysis which are increased in volnnoe are the
calf muscles, the glutei, deltoid, supra- and infra-spinati. Muscles which are apt to
be diminished in volume are the lower two-thirds of the pectoralis major, the latis-
simus dorsi, and the teres major. The weakness of the muscles of the shoulder girdle
loads to a very characteristic symptom — ^namely, when one endeavours to lift the
child under the arms the shoulders slip up to the ears. The hand muscles escape.
Deformities such as lordosis and talipos equinus occur from the weakness and coin>
tracture of the respective muscles of the spine and legs.

As in the myopathy with diminished volume, heredity is a potent cause, and one
may find in members of the same family examples of this disease and the other forms
of primitive myopathy. In some members of a family there is myopathy with loai
of volume, in other members increase of volume (pseudo-hypertrophy), a fact specially
pointed out by Duchenne and Charcot. This goes to show that the cause, whatever
it may be, is a developmental one, and that all these diseases are identioaL This is
further proved by the occurrence of both wasting and increase of volume even in the
same patient.

Diagnosis of primitive myopathy. — ^The gradual onset and family history distin-
guish this disease from acute anterior poliomyelitis, which is the usuJ^ cause of mus-
cular atrophy in children. Pseudo-hypertrophio paralysis is not difficult to diagnose
by reason of the enlargement of the calves associated with weakness of the shoulder
muscles. In neuritic muscular atrophy — e,g., multiple neuritis — paralysis exceeds
the atrophy, and sensory symptoms are usually present. Progressive muscular
atrophy begins in the hands, and develops at a later age, and t^ere are fibrillary
twitchings. Neuro -muscular atrophy of the peroneal type is described below.

Prognosis. — All cases of muscular dystrophy have a progressive course, though
very slow, lasting from ten to fifty years. Death occurs by involvement of the
respiratory muscles, pneumonia, or other intercurrent maladies. In pseudo-hyper-
trophic paralysis the prognosis is grave, the child often dying before adult li^ Gowera
says that they rarely live for seven years after the power of standing is lost. Sooie-
times, however, the disease remains stationary for many years.

Etiology. — ^The disease is hereditary, and symptoms are most frequently noticed
before puberty. Males are more often attacked than females. It is transmitted
generally through the mother, she being healthy. These muscular dystrophies are
closely associated on the one hand with progressive muscular atrophy, duo to keioa
in the anterior horns of the cord, and with the neuro-muscular or peroneal atrophy
which is probably due to changes in the nerves.

Treatment. — ^The progressive wasting appears to be retarded when carefuUy seie^ed
gymnastic exercises are given, and electricity and massage may aid. In the pseudo-
hypertrophic form it is important to retain the power of walking as long as possible.

Progressive Neoro-Muscolar Atrophy (Synonym : Peroneal Typo of Muscular
Atrophy) is associated with the names of J. M. Charcot, Pierre Marie, and Howard

§604] NEURALGIA 863

Tooth, who havo described it. It forms a oonneotlng link between progressive mns-
cular atrophy and the mnsoular dystrophies above desoribod. Like the dystrophies,
it is hereditary, and commoncos in childhood. It is of gradual onset, usually attack-
ing first the peroneal muscles. loading to olub-foot (pes cquinovarus), but it may
begin in the hands. The intrinsic muscles of the hand are affected, as a rule, several
years later than the legs. There are fibrillary twitchings, slight sensory changes, and
diminished excitability to electricity with reaction of degeneration. Gradually. the
wasting extends all over the body. When a case is first seen it may bo difiioult to
diagnose from an old-standing case of acute anterior poliomyelitis, but the latter is
not hereditary, and has no sensory symptoms. As a cause of acquired club-foot this
disease should bo remembered, and ** claw-hand " in childhood is practically always
due to this disease.

AmyotonU Congenita is a congenital condition of extreme flaocidity of the muscles,
with absenoe of deep reflexes, without paralysis, and with lowered faradio excitability.
Owing to the lack of tone in the muscles, the joints can be placed in any position.
The ikoe is usually exempt. The sphincters are unaffected.

Arthritio Amyotrophy. — ^It was, I believe, Charcot^ who first pointed out that joint
lesions are sometimes followed by muscular wasting, quite independently of the
disuse which may attend the injury or disease of the joint, since it may supervene
too rapidly to be explained in that way. It may follow a contusion or joint trouble
which was so slight as to bo overlooked. The atrophy in such cases has three clinical
features : (i.) It is limited to the muscles which move the affected joint ; (ii.) it pre-
dominates in the extensors ; and (iii.) there are no qualitative electrical changes,
only a quantitative diminution. When the arthritic trouble is cured, massage and
electricity will speedily restore the amyotrophy.

GROUP F. PAIN AND SENSORY SYMPTOMS.

Pain,

Pain is a symptom which has been referred to many times in this work,
and the importance of investigating its position, character, degree, and
constancy has already been insisted on. Pain is present in maliy nervous
disorders, but in Neuralgia and Migraine it is almost the only symptom.
. § 604. Neuralgia may be defined as a paroxysmal pain referred to the
seat of some sensory nerve or its branches, in the absence of any obvious
local organic affection. We will first consider neuralgise in general and
then certain recognised tjrpes.

The pain of a true neuralgia is usually described as sharp, shooting, or
knife-like, with paroofysmal exacerbations, and between the exacerbations
there is a dull aching pain. It is usually associated with localised tender
spots, especially at certain points called the " points of Valleix," by whom
they were first studied. Destructive lesions of a sensory or mixed nerve
cause mainly anaesthesia. Irritative lesions of the spinal ganglia (or their
analogue the Gasserian ganglion), or of the sensory fibres on either side
of these, cause pain, and may be attended by vascular dilatation, redness,
oedema, and various trophic changes of the area of skin in which the
sensory fibrils terminate. Herpetic vesicles are prone to appear ;2 and,
in long-standing cases, atrophy of the skin (glossy skin) and subcutaneous
tissue may ensue.

^ '* Lemons Oliniques sur les Maladies du Systeme Nerveux/* tome iii.
^ The author has elsewhere shown that herpetic vesicles are a definite indication,
not of a destructive, but an irritative lesion {Clinical Journal, September 7, 1898).

864 THE NERVOUS SYSTEM [ f 9H

Clinical Investigation and Causes of Neuralgia, — The causes differ some-
what with the seat of the neuralgia, but certain general causes may be
mentioned in the order in which the examination of the case should pro-
ceed— ^viz. : (a) Local, (6) reflex, and (c) constitutional causes, (a) A
careful local examination should always be made of the nerve trunk
chiefly involved — i.e., in the position where the pain started, to see if it
be the seat of tenderness, or other signs of irritation. The parts b^ieath
and around the nerve should also be examined to see whether it be pressed
upon by a tumour or disease of the bone through which it passes, or any
other lesion ; for instance, what appears to be an intercostal neuralgia
may be due to a small patch of dry pleurisy, or the pressure of a swollen
gland, or rheumatic nodule. (6) In many cases of true neuralgia, some
reflex cause, sometimes of a very trivial nature, is in operation, and the
discovery of this depends very much on the clinical acumen of the phjrsiciui.
This is especially true of trifacial neuralgia, where a source of irritation in
the teeth or some other part of the body is so frequently overlooked. The
teeth may, to all appearances, be perfectly sound, and yet, as I have
frequently found, an inflamed or irritated pulp may be revealed by the
tenderness of some tooth when tested by tapping or the application of
hot and cold liquids alternately, (c) Constitutional and general conditions
act mainly as predisposing factors. Neuralgia is essentially a disease of
adidt life ; it is rare in children, and not conunon at the other extreme of
life. It is said to be more conmion in the female sex, and a nemotic
family history is often obtainable. Neurasthenic, nervous, and hysterical
subjects are certainly more sensitive to pain, and more liable to be attacked
by neuralgia. Anaemia is often in operation, and over-fatigue of mind or
body, anxiety, over-lactation, unhygienic surroimdings, or any ol^er
debilitating influence, may predispose to or determine an attack. Con-
valescence from an acute illness, tuberculosis, and various other cachectic
states afford predisposition to attack. Neuralgias are frequently a^o-
ciated with gout, rheumatism, and ague. Many other toxic influ^ioes
may give rise to neuralgia, such as alcoholism, plumbism, diabetes, and
constipation, and the other conditions mentioned under peripheral neuritis
may be heralded by neuralgic pains. Syphilis may produce nenralgta in
two ways ; the nerve may be pressed upon by syphilitic disease of the
periostemn, theca, or bone through which it passes ; or the nerve maj
itself be the seat of a neuritis of syphilitic origin. The former is the more
frequent. Among the general exciting causes, exposure to cold and dull
is by no means infrequent.

General Remarks on the Treatment of Neuralgia. — ^In all cases the cause
should be carefully sought for, and, if possible, removed. Treatmeot
should be directed to any dyscrasia present, such as gout, rhemnatasm,
ague, anaemia ; the latter especially offers a predisposition to the devdqh
ment of the different neuralgiae. For the rest the treatment resolves itself
into tonics, hygienic measures, palliative measures and radical measures.
Among tonics quinine (in large doses) and arsenic take a leading place;

§ 604 ] NEURALGIA 855

iron, phosphoms, and cod-liver oil are also useful. Nervous excitants,
such as strychnine, should be avoided when the nervous system is ex-
hausted, and nerve sedatives, such as bromides, administered when the
nervous system is irritable. The nutrition should be attended to, cod-
liver oil, and two or three pints of milk a day being given in addition to
other food. Alcohol, as a rule, shoidd be avoided, though it may relieve-
temporarily. Over-feeding, combined with perfect rest, the liver being
attended to, often succeeds where other measures have failed. The
patient should be kept in bed, and fourteen to sixteen hours of sleep per
diem should be procured by large doses of bromide. Warm baths are
certainly of great value, and I have sometimes been able to cure painful
affections that have resisted all other means by Turkish baths, regularly
and freely administered. The internal foUiative remedies are numerous.
Among the modem remedies, phenacetin, 5 to 10 grains, antipyrin (com-
bined preferably with caffein citrate), acetanilid, grs. iii. to viii., and
chloralamide are useful. It will be observed that many of the analgesic
drugs are antipyretic as well, a point of interest when we remember that
fever is accompanied by generalised pains ; the two facts together support
the idea that blood conditions alone are capable of producing pain. Tinc-
ture of gelsemium, n\^ 10 to 20 every two hours, certainly allays hypersensi-
tiveness of the nerves, and I have found this combined with n\^20 of tinct.
cannab. indica of use in migraine, an attack of which may be sometimes
thus aborted. They are also useful in other neuralgias. A favourite
palliative prescription of my own is tinct. gelsem. n\^x., antipyrin, gr. v.,
am. brom. gr. x., aq. chloroL Jss. every three hours till relieved. Croton
chloral, paraldehyde, and drugs of that class may also be useful, but their
effect on the heart should be watched. Bromides, among which I believe
bromide of ammonium to be the best, given regularly, combined with
the " rest cure " (vide supra), are especially useful when uterine condi-
tions are suspected. Chloride of ammonium in large doses is sometimes
useful, especially for ovarian neuralgia. In the neuralgia of anaemia,
inhalation of amyl nitrite often affords relief. I have often found that
glonoin affords relief in neuralgiae of various kinds ; and both these last-
named remedies are invaluable for angina and pains referable to a labour-
ing heart. Finally we have in morphia a prince of remedies, either hypo-
dermically or internally, but it should never be administered except by
the medical man himself, and then in full view of the possibility of the
development of a habit. The patient need not be informed that morphia
is the drug which is administered to alleviate his pain. Minute doses of
morphia hypodermically may possibly have a curative as well as a pallia-
tive action on- some neuralgias depending on neuritis.

Chief among external pcMiatives is warmth, whether by hot water, a
muff-warmer, roasted cotton-wool, or poultices. Counter-irritation (e.g.,
mustard leaf behind the ear), emplastrum belladonna, chloroformum bella-
donnse, are useful ; and menthol and peppermint rubbed in, veratrin or
aconite ointment, or oleate of aconitine painted on a limited area are all

866 THE NEBV0U8 SYSTEM [\m

worth trying. Paquelin's cautery dotted over the course of the nerve
will sometimes produce marvellous results. Electricity may be employed
for neuralgia in two ways. (1) A strong current (faradic or galvanic)
causing pain will occasionally remove neuralgia at once. It acts as a
counter-irritant and is suitable only for slight idiopathic cases and recent
cases of hysterical neuralgia. (2) Weak faradism, galvanism (2 to 5 nu.),
just enough to be felt. Place the positive pole on the seat of pain, and
the negative pole anywhere ; avoid sudden variations in strength of
current. Faradism used as a sedative must be extremely weak, and with
very rapid interruptions. Employ large rheophores weU wetted and gentij
slid an to the desired spot. The pain increases at first but diminishes after
a few minutes. The action is analogous to and equal to the mechanical
percussion (Gowers). Local application of chloroform by cataphoresis^ is
said to be very valuable.

Radical or apercUive measures may sometimes be necessary. Acupunc-
ture, nerve stretching, or neurectomy have all been tried with more or
(mostly) with less success. The removal of a portion of the nerre cer-
tainly relieves for a time, but if the nerve joins again, the pain generaUj
returns, sometimes worse than before, and the risk of trophic lesions b
great. The injection of alcohol into the sheath of a sensory nerve by
means of a special syringe has been lately attended with considerable
success, more particularly in cases of trifacial neuralgia.^ Thesolation
used is Beta-eucaine gr. ii., absolute alcohol 3vi., Aq. Dest. ad ^i.

Trifacial Hearalffia (Trigeminal Neuralgia, Neuralgia of the Fifth Nerre, IV
douloureux, Prosopalgia, " Faoe-Aohe **).---0f all the eensory nerves the fifth is the
most frequent seat of neuralgia, possibly because of its exposed position and tortuous
course through bony passages. The sensory branohes of the fifth nerve arc dis-
tributed to the skin of one entire half of the face, the mucous membrane of the month,
nasal cavities, oonjunctiva and the frontal sinuses ; its other functions are dealt vith
olsowhoro (§ 616). The pain may involve any or all of the sensory branches in tmj-
ing proportions, and may radiate in different directions, and there is usually a oos-
siderable degree of tenderness, many tender spots, sometimes redness and oBdena.
In cases of a purely reflex nature this is all. But irritative lesions of the Gaasenu
ganglion, or parts of the nerve in front of this, are indicated also by various tikv
motor and trophic troubles. In cases of moderate severity vascularity and codeon
of the face, watering of the eye, sweating, and sometimes muscular twitchings ani
flashes of light may be observed ; but acute or severe irritative lesions of the fifth
result in herpes of the face or scalp, sloughing of the cornea, pan-opbthalmitis, aad
even swelling and ulceration of the gums. In oases running a more chronic oouzse.
atrophy of the skin (glossy skin) and subcutaneous tissue of the face, and looseniDg
of the teeth may be observed.

The CaiLses may be local, reflex, or constitutional, (a) If any of the iiritatiTr
signs just mentioned be present, we must seek carefully for some load irritative or
inflammatory lesion affecting the nerve trunk or Gasserian ganglion. That tha
nerve may be the seat of de&iite inflammatory lesions is certain from the fact that

^ This is a method which causes the applications to penetrate the skin, and hii
a selective action on the nerve fibres. The method is to soak the sponge of
the positive pole in, say, a mixture of chloroform and alcohol, equal parts, »pp^ ^
over the painful spot, and place the negative pole over the nucha. The cumol
should be just as strong as the patient can l)ear comfortably, and may with advantefF
be reversed every few minutes.

3 Dr. Wilfred J. Harris, the Xancef, 1909, ToL L

§ 604 ] NEURALGIA 867

nmilar sig^ to these appear after an irritative lesion of a nerve-trunk artificially or
experimentaUy produced. Such inflammatory lesions may be due to deeply-seated
bone disease — t.g,, from syphilis or tubercle, or to small malignant growths of the
pharynx involving the nerve. (&) The cause of trifacial neuralgia of moderate severity
is, however, more often some reflex condition, especially that dependent on affections
of the teeth. Decay, the presence of stumps, periosteal disease, or affections of the
gums, or an inflamed pulp, should all be suspected. Sometimes these affections are
obvious, but the last-named (disease of the pulp) is not always so, and may readily
be overlooked for a long period of time, as, for instance, when a late wisdom tooth
presses on the second molar from below. The best sign of pulp irritation is hyper-
sensitiveness to heat and cold in the mouth alternately. Distant organs may also be
a cause in a reflex manner, and these should always be carefully examined in unex-
plained cases. A good many years ago Anstey recorded a case of neuralgia of the
fifth produced by injury to the ulnar, and another case due to injury to the occipital
nerve, (c) Any of the constituiional causes previously mentioned may play their part.
Malaria is a frequent causal agent in the tropics, where it has earned for the neuralgia
of the supra-orbital branch the term " brow-ague.**

EFILKPTI70RM Neubaloia (Trousscau) is a virulent and intractable form of neuralgia
of the fifth, attacking people usually beyond middle life, and consisting of a succession
of attacks of acute darting pain. Its etiology does not materially differ from that of
trifacial neuralgia.

The TreeUmerU of neuralgia is given on p. 854.

Sciatioa is pain in the course of the sciatic nerve. It is difficult to demarcate
sharply between neuralgia and neuritis, and every stage between these occurs in
sciatica. Flrossure and movement increase the pain, and therefore walking and
sitting are difficult. The nerve trunk is tender, and painful points can often be
elicited — e.g., near the posterior iliac spine, midway between the great trochanter
and the tuber ischii, and below the head of the fibula. The sciatic phenomenon aids
the diagnosis. It consists of flexing the leg upon the hip-joint when the patient is
in the recumbent posture. Owing to the stretching of the sciatic nerve this process
causes pain, which disappears on flexing the leg on the thigh. Symptoms occasionally
noticed in chronic cases are fibrillary tremor and slight atrophy. When ansBstheeia,
atrophy, loss of knee and ankle jerks, and partial R. D. are found, the case is one of
neuritis, and pressure within the plevis should be suspected ; and if on the left side
carcinoma of the sigmoid flexure. Hip-joint disease does not cause pain limited to
the sciatic nerve. In spinal disease the pain is usually bilateral.

Prognosis. — Sciatica may recover in a few weeks, or it may last for years, especially
in the aged. Much depends on the early treatment. It is apt to recur. Complica-
tions such as herpes and other cutaneous eruptions are rare. Occasionally the disease
ascends the nerve to the cord, with corresponding symptoms.

Etiology. — Sciatica affects men more than women in the proportion of 6 to 1. It
occurs mostly between thirty and fifty, and is unknown under fifteen. Rheumatism
and gout attacking the sheath of the nerve are the chief predisposing causes. Ansmio
neurotic people of a rheumatic diathesis also suffer. Exposure to cold is the usual
exoiting cause. Tumours, especially cancer of the rectum or sigmoid flexure, exten-
sion from hip disease, peri- or para-metritis, and a loaded rectum, are the chief local
causes of sciatica by pressure within the pelvis.

Tretiifneni. — In the acute stage rest is all important, and particularly the avoidance
of movements (such as bending the thigh) which stretch the sciatic nerve. Heat is
the next most important palliative agent. Mustard plasters and blisters may perhaps
abort the attack (see also Treatment of Neuralgia). In the later stages and for chronic
oases galvanism, nerve-stretching, counter-irritants, acupuncture, with or without
cocaine or morphia injections, may be tried. Injections into the sheath of sod.
salicylate, air, and distilled water may also be used. Alcohol injections must not be
tried. The nerve may be stretched daily in chronic cases by forcible bending of the
thigh on the abdomen, the foot being flexed all the time. Any rheumatic or other
diathesis present must be treated, and remedies which I have frequently employed
with great benefit are guaiacum, sulphur, or chian turpentine (see also Neuralgia,
supra).

868 THE NEB VO US 8 7 STEM [ §

Meralgia ParsBfthetioa is a neuralgia affecting the outer aspect of the thigh in the
area of distribution of the external cutaneous nerve. It is brought on by exeidse.
probably owing to the stretching of the fascia lata. In some oases the presence of
defective sensation points to neuritis rather than neuralgia.

In Brachial Neoritii (inflammation of the nerves of the arm), the main symptom
is severe neuralgic pain shooting down the nerves of the arm. There may also bp
paresis of a greater or less degree, muscular wasting, and the other symptoms men-
tioned under Neuritis (§ 569, single nerve). It is met with in an acute and more or
less chronic form, but in any case it is a severe and often intractable condition. Only
one arm is usually affected, and the condition may have to be diagnosed from an
dccupation neurosis by the circumstance under which it occurs.

Any of the Causes of neuritis may be in operation, but particularly the tozie or
constitutional conditions. I have met with a certain number of cases of brachial
neuritis in which the most careful investigation has failed to discover other deter-
mining cause than exposure to cold, though some of these patients have bem rheumatic
or gouty subjects. Pressure on the nerve in osteoarthritis may lead to neuritis

In regard to the Treatment of brachial neuritis there are two means which generaUj
effect considerable benefit in cases of brachial and other varieties of neuritis due to
toxic causes. (1) The application of Paquelin's thermo-cautery in a white-hot con-
dition rapidly dotted down the painful limb. If the point be made only red, it atioks
to the skin and causes great pain, but if white-hot, it really causes very little incon-
venience, and gives so much relief in these x>ainful cases that the patient asks for
more. (2) The application of galvanism may be of great value to relieve the pain and
improve the nutrition of the muscles (see also Neuralgia, supra).

Neuralgia may affect any of the other nerves (sensory or mixed) in the body bemdes
the three types specially referred to above. The chi^ causes of pain in the vmrioos
situations will now be briefly mentioned. Head's sensory areas may be oonsulted
in such cases.

Painf in the Limbs have been discussed in § 422.

Intercostal Heoralgia of an inveterate kind frequently precedes, aocompanies or
succeeds zoster (shingles), especially in old people. Sometimes it is due to pteesme
of a tumour on the spinal nerves, meningeal thickening, or vertebral disease. If the
pain be persistent in a male over thirty years of age, aneurysm of the descending oovte
may be suspected. The pain may be on one or both sides, and often shoots down
the left arm. As in other neuralgisB, it may be due to a chitt or any of tiio other
causes mentioned above.

Neuralgia hi the Ohest is a common accompaniment of affections of the pleura and
pericardium, but is rare in those of the lungs and heart. However, in cases of canfiae
valvtdar disease and disease of the aorta, the pain may occasionally be of a vezy
aggravated character, and may be attended by a sense of suffocation and impending
death (angina pectoris).

Mammary and Infra-Mammary Neuralgia are generally the result of Aysforio, hst
the organ should be carefully examined for adenoma in the young, auxinoma in the
aged. The word *' agony " used by a female patient in connection with the pain is
sometimes an aid to diagnosis. Pain in the breast is sometimes reflex from uterine
disorder, functional or organic.

Gastric Neuralgia is somewhat rare. It is an intermittent pain in the region of the
stomach, attended sometimes by nausea and even vomiting, relieved rather than
aggravated by food or pressure, unattended by loss of flesh or strength, the digeetioii
being good in the intervals. Gastric pain is one of the four classical symptoms ol
Addison's disease, the other three being progressive emaciation, vomiting, and pig-
mentation. Tabes dorsalis is attended by attacks of severe pain in the ston^i^
(gastric crises), and similar attacks are met with in pernicious anfemia. Hydrooyaoii
acid is worth trying in all intestinal neuralgiie.

Abdominal Pains are described in Chapter IX.

Neuralgic Pain in the Neck is suggestive of stiff -neok ('*rheumatio "), spinal cazies,
or other local affection. Pain in Uie occiput and back of the neck is frequent m
gastric and hepatic disorders. Occipito-oervical neuralgia is a somewhat rare fom
of idiopathic neuralgia, probably of reflex origin.

§605] MIGRAINE 859

Sidnal Neuralgia may arise from spinal caries or some other disease of the spine
or theca pressing on the posterior roots. It is generally inoreasod by exertion, and
there is a oharaeteristio history. Meningeal affections give rise to paroxysms of pain
in the region of the spinal nerve roots, shooting round to the front on both sides, or
down the limbs, accompanied by great tenderness on movement, and perhaps anies-
thesia.

Neuralgia of the dorsal spine is a very frequent and troublesome symptom in
neurasthenia and hysteria, in which oases more tenderness may be produced by light
touches than by deep pressure, and movement may not aggravate it. Similar to the
foregoing is the pain in the spine, which forms one of the most intractable results of
railway accidents (railway spine). It is usually accompanied by tenderness, increased
by sitting, or by the vibration of a train. In dyspepsia or gastric nicer pain is often
referred to a tender spot in the mid-dorsal region. A constant grinding or boring
pain in the dorsal region, shooting, perhaps, round to the side and front in a male
adult, is always suspicious of aneurysm. In the young and delicate pain in the back
may be due to laxity of ligamerUs, Under these circumstances it only comes on after
sitting or standing upright, and leads to stooping. It is best treated by carefully
regulated gymnastic exercises.

Lumbar Neuralgia may herald variola, erysipelas, or influenza, or arise reflexly from
uterine, renal, and other visceral diseases. Lumbago is described in § 443.

§ 605. Migraine (Synonyms : Megrim, Sick Headache, Nervous Headache, Paroxys-
mal Hemicrania) may bo defined as a headache having a paroxysmal character, and
running a more or less definite course, occurring at intervals over a long period of
time, generally ushered in by malaise, and frequently associated with and relieved by
nausea and vomiting.

In the Symptoms tiiere are usually two stages. The first stage is attended by some
transitory disorder of sensation, such, for instance, as bright spots or dark figures or
lines before the eyes (scintillating scotoma). In some individuals other sensations
are complained of, such as a feeling of chilliness or of cold feet, or of mental depres-
sion, with a dread of impending evil, or restlessness, or pins and needles in the limbs.
This stage may last from five to thirty minutes, or longer, and is then succeeded by
the second stage — that of headache — which is usually very severe, and lasts from a
few hours to two or three days. It generally commences in one spot, and gradually
involves one half or the whole of the head. It is usually terminated by a feeling of
nausea and actual vomiting, after which the headache passes away. It is distin-
guished from other varieties of headache by its paroxysmal character, periodic recur-
rence, its definite march, and by its usually being preceded by sensory disturbances
and followed by vomiting.

Causes, — ^Megrim is an eminently hereditary disorder. It is, like most other
paroxysmal neuroses, more frequent in the female, affects early and middle life
chiefly, especially women at the climacteric. Attacks are certainly predisposed to by
any general want of tone in the system, and determined by anything of a depressing
or exhausting nature, physical or mental, such as grief, anxiety, or bodily fatigue,
improper food, or impure air.

Prognosis, — ^Megrim usually starts soon after puberty, and the attacks recur until
about fifty years of age, when they gradually become less frequent. It is never fatal,
but is very often of such severity as to completely prevent the person following her
avocation during the two or three days of an attack.

Treatment, — (1) For the attacks : If slight, a cup of strong co£^, or a walk, or
drive, or oheerhd companionship, will help to stave it off. But if severe, the patient
must be kept in bed, and perfectly quiet, in a darkened room, with nothing but iced
milk to drink. Bromide, 10 grains every hour with a little sal volatile, may be com-
bined with phonacetin, antipyrin, and many of the other drugs mentioned under
Neuralgia. In some oases chloride of ammonium, in doses of 16 grains, or guarana
powder relieves. If these means fail, any of the following may be tried : caffein,
cannabis Indioa, croton chloral, gelsemium, and amyl nitrite. The latter inhaled
often gives wonderful relief, and strongly supports the theory of vaso-motor origin.
That it fails in some oases is readily understood, because the poison, whatever it may
be, is still circulating in the blood. (2) Between the attacks the mode of life should

860 THE NERVOUS SYSTEM [f

. be regulated bo as to avoid any known exoiting condition. And as regards food, thcfo
are throe opposite modes of treatment. One is to diminish the diet as much as pos-
sible, and especially in its nitrogenous constituents ; the other, with which I have
met with more success, is to give a liberal dietary, with copious libations of milk, in
addition to the ordinary diet, and two glasses of old Burgundy with each of the two
chief meals. Another method, which has also been attended by much success, is that
recommended by Dr. Francis Hare — ^namely, limitation of tho carbohydrates- Any
reflex cause of irritation — e.g,, eye-strain — must be searched for and removed. Sali-
cylate of soda, in view of Haig*s researches, which certainly have much to support
them, is a valuable remedy, and should be taken regularly. Morning and evening
glasses of hot water to purify the blood, combined with an occasional purge, arc
useful. Tonics, as a rule, arc of very littie use (see also Neuralgia).

Cutaneous Sensation.

§ 606. Difloirdera of Gataneons Sensation are rare as substantive affections
apart from motor defects, excepting in hysterical cases. Moreover, when
motion and sensation are simultaneously affected, as after division of a
mixed nerve, the loss of sensation is less and is recovered from much more
quickly than the loss of motion. Symptoms referable to cutaneous sensa-
tion may be grouped into Hemiansesthesia ; Anaesthesia of the lower half
of the body ; Localised AnsBSthesia ; H3rpersBsthesia ; Parsesthesia and
perverted or subjective sensation. Syringomyelia may be appropriately
described in this place.

The CuNiGAL Invbstioation is given in { 517. Time and patience are required
to elicit the precise nature of the defect and its boundaries. AU three kinds of sensa-
tion may be lost ; tactile and painful generally go together, thermal may be lost alooe.
Muscle sense is not connected with the skin ; it is the sense of position or degree of
contraction of a muscle.

HemiansBsthesia, or loss of tactile sensation in one half of the body, may be due to
either functional or organic causes, the former being far the most f requ^itw

1. In Hyiteria, anaesthesia, and particularly hemiansBsthesia is such a frequent
symptom as to form one of the hysterical stigmata. Hysterical hemianaostheeia ba«
special characteristics of its own, which enable one to recognise the condition from
these alone, (i.) In its typical form it is complete, more absolute than any otbor
hemiansBsthesia, and involves not only the skin and mucous membranes, but ^bo the
joints and muscles, (ii.) It is sensorial — i.e., involving the special senses, as well as
common sensation. Vision alone may be partially retained on the paralysed side.
but in its characteristic form this sense also is altered by a contracture of the fie&d
of vision on both sides, more marked on the ansesthetio side. There is also an inver-
sion of the colour fields.^ (iii.) The hemiansesthesia varies from day to day. and
perhaps from hour to hour, and may shift suddenly to the opposite side «kfter some
emotional shock. It may be accompanied by paresis of varying degree on the same
or the opposite side, or tho other side may be hypersesthetic. (iv.) The oonditioo
may also be recognised by the presence of the other three hysterical stigmata — ^vIl,
globus, fainting or nervous attacks, and the ovarie. This latter consists of a hyper-
aesthetic patch in the inguinal region, which is known as the ovarian tenderness,
thotigh it is wholly independent of the ovary, for it is present in the male.

2. Organic Lesioni of the Brain or Spinal Cord may also give rise to hemiangsthesia.
though it is usually less profound than the preceding, and is accompanied by panlysb
of the same side.

(a) Hemiansesthesia, sensory and sensorial, duo to a very extensive organic lesioo
of the cortex, is recognised by convidsions and paralysis having a distribution corre-
sponding to the position of the lesion.

^ E.g., a case recorded in the ** St. Thomas's Hospital Reports," 1888.

§ 606 ] DISORDEHa OF CUTANEOUS SENSATION 861

(6) Hemianaasthesia, sensory and sensorial, of a more complete kind than the pre-
ceding, may be due to a lesion at the posterior end of the internal capsule (sensory
crossway), and is known by being accompanied by slight hemipareeis, the leg being
more involvod than the arm, because the leg fibres pass down the posterior part of
the motor tract, adjacent to the sensory crossway.

(c) HemianaBsthosia without loss of sight or smell may arise from a focal lesion
below the internal capsule, but above the pons — a small hemorrhage into the teg-
mentum of the cms, for instance.

{d) Crossed hemiansesthesia (one side of body, other side of face) may arise from
a lesion in the fillet or pons, in which case it is attended always by crossed hemiplegia.
Crossed hemiannsthesia may also arise from damage to one of the peduncles of the
cerebellum, especially the middle one, and is then probably accompanied by paresis,
staggering gait, vertigo, etc.

AnsMthesia of the lower half of the body or loss of tactile sensation of the legs and
lower part of the trunk is very rarely functional. It indicates practically in all such
cases an organic lesion of the cord, and is accompanied by paralysis. The segment
of the cord involvod may be localised by the upper limit of the ansBsthesia. It will
also bo remembered that in myelitis a narrow band of hypersesthesia is a good indica-
tion of the upper limit of the mischief, which may also be localised by means of Head's
algesic areas (§ 658).

Brown-Siguard Paralysis. — A stab or bullet wound strictly limited to one half
of the cord produces on the opposite side loss of tactile (partly), and loss of pain- and
temperature-senses ; on the same side loss of power, sense of tactile position and
discrimination (by compasses. Head) and vaso -motor tone. At the level of the lesion
on the same side is a band of ansBsthesia with a band of hypersesthesia above it.

Localised or Limited AnnsthesU. — (1) Hysteria is the commonest cause of com-
plete SEGMENTAL ansBsthesia of one limb — i.e., one which is limited by a horizontal
ring round the level of a joint (wrist, elbow, knee, or shoulder). Such an anaBsthesia
is always cerebral in origin.

(2) Tabes dorsalis is a disease which may be suspected when there are small patches
or streaks of lost or modified sensation. All manner of sensory variations are met
with in the preatazic stage, such as anaesthesia of the soles of the feet or along the
ulnar margin of the wrist, delayed sensation, a zone of an- or hyper-SBsthesia round
the body, or transferred sensation (allocheiria).

(3) Syringomyelia is a spinal lesion characterised by muscular atrophy and thxbmal
AN.£STH£SIA of One or more extremities, not infrequently the arms, tactile and pain
sense being retained (§ 607).

(4) Lesions affecting the spinal nerve roots — e.g,, spinal caries or tumours — ^produce
PATCHES of ansBsthesia along the limbs, and are accompanied by severe neuralgic pain.
A transverse lesion of a spinal segment not involving the spinal roots is unaccompanied
by pain. The distribution of the anaesthesia is given in the figures in § 558, and it
differs from that due to peripheral nerve lesions.

(5) Peripheral neuritis and destructive lesions of the peripheral nerves also produce
similar patches of anaesthesia in their areas of distribution (Figs., § 569) ; but it should
be remembered that loss of sensation is produced much less readily than loss of motion.
In multiple peripheral neuritis there is very often analgesia with preservation of the
tactile sense quite at the ends of the limbs. In lesions of the nerve trunks (neuritis,
leprosy, etc.) the distribution of the anaesthesia corresponds only roughly with the
distribution of the affected nerve, the adjacent areas overlapping considerably. But
in lesions of a spinal root or of a spinal segment the area of anaesthesia does not corre-
spond with the distribution of the nerves connected with that root, and the margins
of the analgesic areas are abrupt and definite (see Head's Areas, § 558).

AnsBsthesia Dolorosa is a condition of anaesthesia attended by neuralgic pains*
present sometimes in peripheral neuritis, local or multiple.

Hyperaasthesia. — Much that has been said about anaesthesia applies also to h3rper-
SBsthesia, for irritative lesions will produce this latter condition where destructive
esions produce anaesthesia.

General Hyperassthesia occurs in hysteria, hydrophobia, and rickets. It is also found
combined with the neuralgic pains in spinal meningitis (especially the acute form).

862 THE NEB VO US S Y8TEM [ §

Localised HypercBsthesia. — In alooholio or other multiple neuritis the muades. nerres.
and skin are often acutely tender. The band of hypersosthesia in myelitis associated
with girdle pain has already been referred to. It is a marked feature in canoer of
the vertebrsB and in acute spinal oaries.

In neuralgia hypercBstheiic spots on the skin are met with in the distribution of the
affected nerve.

Tender areas may be associated with irritation of certain spinal root zones or with
visceral disease (compare § 558, Head's Sensation Areas). But perhaps the most
common cause of hypersesthetic spots is hysteria. Such spots are found very con-
stantly in hystericfld oases in the inguinal (so-called ovarian), infra-mammary and
sometimes in other regions. If pressure over these spots gives rise to hysterical
attacks of any kind, they are called hysterogenic zones.

ParaMthesia (perverted sensation) in its strictly etymological sense means the per-
yortod perception of an external stimulus. Used in this sense it is met with either
in the form of (i.) transferred or misplaced sensations (allocheiria), when the patient
locates a tactile sensation to the opposite side or some other part of the body ; or
(ii.) delayed sensation. Both these alterations are met with in tabes dorsalis. and
they may also be present in hysteria and sometimes in syringomyelia. Polynesikesia
indicates an apparent multiplication of the parts touched. But the term " par-
a^sthesia ** is also frequently used for various subjective sensations independent of
external stimuli, such, for instance, as the numbness, tingling, creeping cold sonsatioos
which are met with in the early stages of peripheral neuritis.

Neurasthenia is frequently accompanied by a number of perverted sensations, such
as burning, crawling, throbbing, etc. In tMs disease also we meet with thooe inde-
scribable somatic sensations, in which, for example, the patient feels as if he were
** sinking through the earth,'* ** treading on air," or a general feeling of bodily dis-
comfort, such as words fail to describe.

AcroparcBsthesia also comes under this head. It is a symptom but little referred
to in books, but is common enough in out-patient practice. The patients compUin
of a feeling of coldness, pricking, smarting, pins and needles, and often severe pains
in the hands. It is a symptom of many nervous and gastric disorders, and may go
on to erythromelalgia (§ 429).

§ 607. Syringomyelia and Intra-Medollary Tamouri {i.e., within the spinal cord).—
Tumours within the spinal cord consist mainly of syphilitic gummata, syringomyelia
with or without gliomatosis, sarcoma, tubercle, and myxoma. They are less frequent
than the external and extra-medullary tumours (see Compression Paraplegia, § 557).
and give rise to a very different set of symptoms. They involve the grey matter and
the central parts of the cord primarily, consequently paraplegia and pain are usuaUy
absent until late in these diseases, and only arise as a result of the secondary lateral
sclerosis. Syringomyelia is an interesting condition which has received oonsideraUe
attention of late years. It consists essentially of a patency or dilatation of the oential
canal of the coid, the epithelial lining of which is prone to take on a gliomatoos
(small-celled ? sarcomatous) growth having a malignant tendency to spread upwards
and downwards. The chief seat, and therefore presumably the origin of this new
growth, is the cervical region, and consequently one or both arms exhibit the earliest
symptoms.

The SympUmis of these conditions vary somewhat with the position and the part
of the cord involved (Spinal Localisation, § 558), but the commonest position is the
anterior part of the posterior columns in the cervical enlargement, and we meet,
therefore, with three principal symptoms : (1) Loss of sensibility to thermic impres-
sions, and sometimes to painful impressions, tactile sensations being sometimes
retained, chiefly, but by no means always, limited to the hands and arms, is the
most characteristic symptom, and is not known to occur so typically in any other
disease. Thermic, painful, and tactile sensations are all translated simply as touch.
(2) Muscular atrophy in one or both arms occurs as the tumour extends forwards,
accompanied by B. D. (3) Later on there are paraplegic rigidity, increased reflexes
and spasms due to descending sclerosis. In one case under my care there was atrophic
flaccid paralysis of the legs, with greatly increased knee-jerks and ankle cloniis.
Diminished power of the limbs on one side with diminished sensation on the other

§§ 608, 609] S YRINQOM YELIA AND INTRA-MEDVLLAR Y TUMOURS 863

(BfowD-S^quard phenomenon) may be met with if the lesion extends laterally. Com-
bined with the thermal ansBsthesia and atrophy in the arms and the spastio paralysis
in the legs are a number of other symptoms which may or may not be present, such as
various trophic lesions of joints and bones. At other times there are vesicles, bullse,
extensive desquamation of the cuticle (in one case under my care the epidermis of the
fingers was shed like a glove), ulcerations, or whitlows (which, coming on without
pain, resemble the painless whitlows of Morvan's disease), all of which chiefly affect
the upper extremities. When the lesion spreads to the medulla and pons the cranial
nuclei are apt to become involved, causing nystagmus, deranged respiratory and
cjirdiac movements, paralysis of the vocal cords, tongue, palate, or pharynx. Sudden
death may ensue, as in the case just mentioned, from extension to the ** noeud vital.**
These are the symptoms of tumours in the cervical region and of syringomyelia. In
the other positions intra-medullary tumours give rise to symptoms which depend on
the column mainly involved.

The Diagnodis is difficult in the earlier stages. The pathognomonic symptoms of
syringomyelia are thermal anaesthesia, combined with atrophic paralysis. Progressive
muscular atrophy has no such impairment of sensation. In multiple peripheral neuritis
the symptoms are more scattered. Hypertrophic cervical meningitis is characterised
by severe pain, and the ansBsthesia, if present, involves all forms of sensation.

The Prognosis depends upon the position and rate of advance of the disease. Syringo-
myelia usually runs a very slow but progressive course of many years imless the
neoplasm extends rapidly upwards and causes death. Other cases in which apparently
no gliomatosis occurs, and in which some joint^ or other trophic manifestations are
the only symptoms, may live to old age.

Causes, — Syringomyelia is probably due to a congenital condition of the cord, but
the age at which the symptoms are first noticed is not often under fifteen, and very
rarely over thirty. It is more frequent in males (two-thirds). The symptoms have
often been noticed to follow an accident of some kind. The central canal (so-called)
of the cord consists normally of a solid rod of epiblastic cells remaining from the
grooved infolding of that stricture which develops into the spinal cord. Everything
tends to prove that this remains patent in syringomyelia, and that the cavity enlarges
and involves the adjacent trophic and sensory tracts, especially that of the tempera-
ture-sense. In some cases the condition remains stationary, and the patient lives
indefinitely ; in others gliomatosis occurs in the epiblastic cells (determined, perhaps,
by a slight injury to the back), and the patient dies in a year or two. Or syringomyelia
may consist of multiple cavities in the cord, with or without gliomatosis, these afford-
ing a predisposition (Gowers says a necessary predisposing factor) to hsamorrhage into
the cord.

The TreatmeTU is symptomatic ; iodide may be tried. X-rays have been useful,
applied over the spine.

GROUP VI. CRANIAL NERVES AND SPECIAL SENSES.

§ 608. The investigation of the cranial nerves and special senses is of
great importance from the standpoint both of general medicine and
neurology. A tabular statement of their functions will be found
on p. 864.

§ 609. The First Nerve is the olfactory bulb. To test the power of smell
on one side close the other nostril with your finger and tell the patient to
sniff some odour such as peppermint, clove oil, or onions (not ammonia,
which is a stimulant to the second division of the fifth nerve in the nasal
mucous membrane), and see if he can name the odour. It is convenient
to have some little bottles containing these substances.

^ As in a case exhibited by Mr. J. R. Lunn at the Clinical Society of London in
London in 1890 or 1900.

864

THE NERV0V8 SYSTEM

l§

Table of Cranial Nerves and their Functions.

Cranial Nerves.

Ftmetions. ,

I. Olfactory nerve.
IT. Optio nerve.
III. Motor ocoli.

Smell.

Sight.

Supplies all the muselee of the eyeball (except the mpenor obliqiie
and external rectus) and the levatOT palpebrae superkvis ; also ;
the sphincter pupilte and ciliary muscle. ,

IV. Motor oculi.

Supplies the superior oblique ; turns the eye down and oatwarda.

VI. Motor ocnli.

Supplies the external rectus ; turns the eye outwards.

V. Trigeminal nerve.
First division,
Ophthalmic.

Second division,
Superior
maxillary.

Third division,
Inferior
maxillary.

r Sentory to forehead and part of vertex, anterior part of nose to
< tip, upper eyelid and temple, eyeball and lachrymal gland.
V Contains dilator pupilUs fibres from sympathetic

"Sensory to cheek, lower eyelid, side of nose and upper lip ; the
upper teeth and gum ; lining membrane of nose, roof of movth,
soft palate, tonsils, and roof of phanmx.

1 Taste of anterior two-thirds of tongue (through Meckel's ganglifwi
by chorda tympani nerve).

^Trophic and vaso-motor fibres.

' Sensory to lower part of face, lower lip, side of head, ear, Umgve,

lower teeth, gum, and inner side of cheek.
Motor to masticatory muscles, temporal, masseter, pterygoids '
anterior belly of digastric and mylo-hyoid, tensor tympani
and ? tensor paUti. •
Taste of anterior two-thirds of tongue (by diorda tympani froim 1
lingual nerve) ; of posterior one-third of tongue through
^ gloeso-pharyngeal nerve, Jacobson's nerve, and otic gan^hoo.

VII. Facial nerve.

Motor to all muscles of face and scalp (excepting levator palpebnc
superioris), platysma, posterior belly of digastric, and stapedios
muscle.

It is joined by the chorda tympani (conveying taste fibres of an-
terior two-thirds of tongue from lingual l^anch of V. to Meckel's
ganglion).

VITI. Auditory nerve.

IX. Glossopharyngeal
nerve.

Hearing.

Sensory from pharsmx.

Collects taste fibres from posterior one-third of tongue, which

ultimately join V.
Motor to middle constrictor of pharynx and stylo-pharyngeos.

X. Vagus nerve.

Motor for soft palate (except i&naat palati), phsjynx and larsrnx

(through accessory portion of XI.).
Motor (involuntary) and sensory for heart, respiratory paasases

and abdominal viscera (through sympathetic gani^).

XI. Spinal accessory
nerve.

Motor to stemo-mastoid and trapezius.

(Supplies vagus with motor fibres for larynx, pharynx, and
palate.)

Xn. Hypoglossal nerve.

Motor to tongue and depressors of hyold bone.

Anosmia is loss of smell ; parosmia is a perversion of smell. Loss of smell often
depends on atrophic rhinitis or some other nasal disorder (see Chapter VEL). The
first nerve alone may be damaged by concussion, the fine branches becoming ton
against the cribriform plate of the ethmoid. This is extremely difficult to restoie.
In one case I was partially successful by localised cataphoresis with cocaine and
strychnine. Smell may be lost after influenza, diphtheria, and other specific fevers.
after thrombosis or embolism of the anterior cerebral artery, and with tabes dorsalis.
Paralysis of the fifth may produce it by dryness of the nostrils. Hallucinations of

gjQQll i,e., odours recognised when no odorous substance is present — often form the

aura of an epileptic fit.

§ 610 ] ORGAN OF VISION 865

§ 610. The Organ of Vision is innervated mainly by four cranial nerves —
the second, third, fourth, and sixth. The fifth and the cervical sym^xUheiic
are also concerned in its innervation. Careful examination of the eye is
of the greatest importance in many diseases.

The symptoms which reveal disease of the eye may be arranged under
six headings : Pain, Superficial Alterations, Acuteness of Vision (§ 611),
Pupils (§ 612), Ocular Movements (§ 613), Changes in the Fundi (§ 614).
The reader should turn to the section dealing with the defect to which
the patient's symptoms appear to belong.

The systematic examination of the eye consists of : I. Investigating

pain if present ; II. noting any superficial alterations ; III. testing the

acuteness of vision ; IV. examining the pupils ; V. the ocular movements ;

and VI. theiundi. But in routine examination for medical purposes the

acuteness of vision is left until the end.

L Pain in the Eyes is not infrequently absent in ooular affections. Its commonest
cause is some error of refraction (asthenopia — i.e., eye-strain). Eye-strain may
cause headache, or a dragging pain round the eyes, or blepharitis and blinking in
children, or neuralgia of the Sth nerve. Glaucoma or any other cause of increased
ooular tension may cause pain. And, as Tomes has pointed out, dental disorders
may not only give rise to reflex pain, but also to both functional and organic affec-
tions of the eyes. Among subjective sensations other than pain may be noted muscso
volitantee (black dots) and scintillating scotoma (zigzag lines). The former occur in
anssmia, debility, or functional disorders of the Uver, the latter in association with
migraine.

II. Saperfidal Alterations mainly come within the province of the surgeon ;
they are six in number. A good light and a lens are all that is necessary.

1. Pboptosis is an imdue prominence of the eyeballs, and is met with in exoph-
thalmic gottre, ophthalmoplegia externa, and in marked myopia. In one eye only it
suggests orbital tumour or some intracranial lesion. To detect small degrees, look
down over the top of the patient's head from behind. Recession of the balls occurs
in paralysis of the cervical sympathetic, the other symptoms of which are contraction
of the pupil on that side and loss of the cilio-spinal reflex (reflex dilatation of the
pupil when the skin of the neck is pinched).

2. The Eyelids. — ^The eyelids are puffy in renal disease, cardiac dropsy, and in
arsenical poisoning. Ptosis, or drooping of the upper eyelid is (i.) one of the symp-
toms of paralysis of the third nerve (infra). It may also be due to (u,) a cortical
lesion, without involvement of any other part of the third nerve ; (iii.) idiopathic
muscular atrophy when the face is affected ; (iv.) myasthenia gravis ; (v.) hysteria ;
(vi.) a congenital condition ; (vii.) Nothnagel has described a pseudo-ptosis, in which
the eyelid gives the appearance of drooping, owing to recession of the eyeball in
paralysis of the cervical sympathetic (§612). A diminution of the palpebral fissure
may be due to recession of the eyeball (ante), or weakness of the levator palpebraa
superioris. Blephabospasm is an involuntary clonic twitching of the eyelid (see
Habit Spasm, etc.). Inability to olosb the eye is a notable feature in Bell's (facial)
paralysis. It is also one of the earlier symptoms in infancy of the hereditary infantile
amyotrophy described by Duohenne.

Dbugibnt Faluno of the Upper Eyelid when the patient looks rapidly down
constitutes the BO-oaUed Von Graefe*s sign in exophthalmic gottre, but this sjrmptom
is only present in an advanced stage of the disease when other means of identification
are not wanting. The same remark applies also to Stellwag*s sign (the almost total
absence of involuntary blinking), and to Mosbius's sign (a deficient power of con-
vergence), which are occasional symptoms in Graves* disease.

The diseases of (3) the conjunctiva, (4) the cornea, (5) the iris, and (6) the alteration
of tension are dealt with in surgical works.

866 THE NERVOUS SYSTEM [\m

§ 611. Defects of Viidon may consist of (1) defective sense of form or
acuteness of vision, (2) alteration in the field of vision, (3) defective sense
of colour.

( 1 ) Acuteness of Vision implies the estimation of forms of objects. It may be
roughly tested by asking the patient to oount the number of fingers held np beion
him. The defect may be so great that the patient cannot perceive light from dad-
ness. The eyes must be examined separately, as it is often found that defect of <bs
eye has existed a long time without the patient being aware of it. If the exteniil
parts of the eye are normal, the media transparent, the ophthalmoscope reTeals bo
disease, and there is defective acuity of vision, it is probable that the patient snSm
from an error of refraction. Asthenopia (eye-strain) is due to continuoas ovenctioe
of the internal muscles of the eye, and is manifested by ocular pain, ciliary oonges^
and headache. Excessive blinking and inability to use the eyes for long at a tin
are often the only symptoms in children. It may be due to overuse of the eyei in i
bad light, but its commonest cause is some error of refraction.

Errors of Refraction. — For accurately testing the visual sense of fonn, tke
power of reading Snellen's types at a given distance (usually 6 metres, or 20 feet) is
employed. The error of refraction is ascertained (after paralysing the iris by homa-
tropin) by placing various lenses in the frame-spectacle before the eyes untH it ii
found which of them completely corrects his error. Convex lenses are indicated bj
the sign + , concave by the sign - . The defect is measured by the fooal length of
the lens required to correct his error, and is now generally expressed in diopteo.
indicated by the sign D. A lens of one diopter has a focal length of 1 metre. 'Au.
a + 3 D. lens indicates a convex lens with a focal length of J metre, being thieetisKi
as strong as a lens of + ID. Retinosoopy is a more accurate method of tatiil
refractive errors (below). In myopia (or near sight) the image is formed in front d
the retina, and the patient cannot see distant objects clearly. In hypennetrofia (or
far sight) the image is formed on a plane behind the retina, and the patient caoMt
look at near objects for any length of time. Both may be due to defective shape d
the globe or, less frequently, to defective accommodation. Concave lenses are inrf
to correct myopia, and convex to correct hypermetropia. In presbyopia the rigidity
of the lens renders it either difficult or impossible to accommodate for near obyecto;
it occurs in old people whose far vision may be remarkably good, though it is ie-
possible for them to read or to see near objects distinctly without convex ^aflK&
Astigmatism is a non-correspondence of the curve in the different meri<^anB oi tk
cornea. In simple astigmatism one meridian is normal, the other myopic or hy^
metropic ; in compouTid astigmatism the error of the two meridians, though of tbe
same kind, differs in degree ; in mixed astigmatism there is a myopic error in o«
meridian, and a hypermetropic error in the other meridian ; in irregtdar astigm^*
the curves of the cornea vary even in the same meridian. Astigmatism is detect
accurately by a skilled examination by retinosoopy, or with the astigmometer.

In retinofcopy the procedure is as for indirect ophthalmoscopy (§ 614), ooly ^-
out the large lens. No details of the fundus are visible in this way, but noraafi! ^
perfectly red field is seen. If the bloodvessels are seen, then the patient's refraetM
is abnormal. Errors of refraction are revealed by tilting the mirror apwards tf^
downwards and from side to side. A dark shadow passes across the field in t^
procedure. In a normal eye the shadow moves very rapidly across a straight, d^v<
edge. The greater the error of refraction the more slowly does the shadow oov
and the more curved and hazy is its margin. If the edge of this shadow mova ::
the opposite direction to the concave mirror, the refraction is either normal, hyp
metropic, or consists of less than one D. of myopia. If there be mjropia of more^
one D., the shadow moves in the same direction. Astigmatism is diaoovered bfO
shadows moving differently in opposite meridians. Opacities in the media aay *
thus detected as dark shadows upon the red field. The radiating streaka ol ^
menoing cataract or moving opacities in the vitreous may also be thus detectod.

(2) l^e Field of Vision is the extent of the picture presented to tlie eye at i^
given moment. It may be roughly tested by instructing the patient to eovft ^
eye and look fixedly at the tip of your nose at a distance of about 2 feet. Thea k«^

§ 611 ] DEFECTS OF VISION 867

up one hand on eaoh side of you in the same vertical plane as your face, and bring
it gradually towards your nose, asking the patient to cry ** stop " the moment it
comes into his view. Eepeat the same procedure below, above, and at the two sides,
and in this way you will roughly ascertain in what part of his field the vision is defec-
tive. The dimensions of the visual field can be tested accurately only by the peri-
meter (below). Scotoma is a word used to indicate a spot of blindness or imperfect
vision within an otherwise healthy field — e,g., a central scotoma is a blind spot in the
middle of the visual field.

The Perimeter. — The patient covers one eye and places the other cheek bone against
the round knob of the vertical pillar ^ inch below the palpebral fissure. The patient
must be educated to keep his eye steadily fixed on the spot opposite, while the operator
moves a small piece of white paper (or coloured for testing colour vision) mounted
on the stick provided along the movable semicircular metal band from periphery
to centre. The position in which the patient can first see the paper (while looking
fixedly all the time at the central spot) is then marked on the chart provided. With
stupid patients this is a tedious operation, and without due care erroneous results
may easily be obtained. The perception of colours in the peripheral field varies
normally in extent with the different colours. Thus, from without inwards they are
white, blue, yellow, red, green.

(3) Ck>LOxrB Vision may be tested by means of a collection of different coloured
wools. The patient should be instructed either to (i.) identify and name different
colours, or (ii.) to pick out all the pieces of wool which match, three or four pattern
pieces being given to him at the outset.

Colour Blindness (achromatopsia) is a symptom in some diseases of the retina and
optic atrophy, both primary and secondary. It is also present in tobacco and some
other forms of amblyopia in their early stages (infra). Partial achromatopsia may be
congenital. In some hysterical cases the colour defect takes the form of dyschroma-
topsia, where the fields for different colours are inverted, the field for red being larger
than that for blue, the reverse of normaL^ Charcot,^ who was the first to describe
this condition, regarded this as a special and quite distinctive feature of hysterical
achromatopsia. Cdoured Vision (chromatopsia) is an occasional symptom after the
extraction of cataract in aged persons, and in exhausted states of the nervous system.
I have met with it in some cases of tabes dorsalis. It is abo occasionally a symptom
ol glaucoma ; red vision (erythropsia) is the most common. Yellow vision is a symp-
tom of santonin poisoning.

The Causes of Defective Tision without any very obvious ocular changes may be
considered under Amblyopia (bilateral and unilateral), hemianopsia, and night-
blindness. The defective vision due to errors of refraction has already been dealt
with.

Amblyopia is diminished vision, Amaubosis loss of vision, without discoverable
changes in the fundi oculorum or error of refraction. It is obvious that amblyopia
may be due either to some functional disturbance of the visual apparatus, or to some
gross lesion of the brain or paths of vision behind the retina or optic discs.

BiLATBBAL AMBLYOPIA may arise under various toxic conditions and functional
states, as follows :

1. Tobacco Amblyopia arises sometimes in hard smokers of over 3 or 4 ounces per
week, or in debilitated persons and women from a much smaller quantity. The patient
first complains of defective vision in bright light ; he sees better at dusk than at noon.
The defect is slowly progressive, becoming most marked in the central part of the field,
and there is central colour scotoma, especially for red and green. At first there may
be no changes in the fundi, then the discs become slightly congested in the earlier
stages, and pale and atrophied especially on the temporal side, in the later. In several
oases which I have seen a defective vision was the earliest symptom to attract the
patient's notice. Tobacco amblyopia, it should be borne in mind, is very occasionally
met with in females.

^ A case is recorded in ** St. Thomas's Hospital Reports," 1888.
2 ** Clinical Lectures on Diseases of the Nervous System," vol. iii. ; New Syd. Soc.
Trans.

868 THE NERVOUS 8 Y8TEM [ § eil

2. Toxic amblyopia is caused also by other poisons such as urssmia, diabetes, large
doses of quinine, bisulphide of carbon in indiarubber manufacture, iodolcMin aod
dinitro-benzol. Little in the way of treatment can be done for such cwsee, unkn
they are seen early, when absolute cessation of the cause and functional rest to the
structures involved m4y lead to recovery.

3. Various Structural Diseases of the Retina and Optic Nerve in their inoipieiit etafot,
when attended by slight alterations that none but a very skilled obeerver can detect,
may, nevertheless, be attended by an alteration of the visual fields and of the acut^
ncss of vision. This is sometimes the case with insidious papillitis, and generallj with
primary optic atrophy. The double primary atrophy which so oft^i aooompanieB
tabes dorsalis is a marked instance of this ; it may precede the ataxy and other ejnp-
toms of tabes by many years. I have seen several such cases, where the amblyopia
was regarded as functional, and its spinal origin overlooked for a long timc^ Primary
atrophy more rarely accompanies disseminated sclerosis and general paralysifl of the
insane. In all these cases the field of vision is diminished, either ecoentrically or cod-
centrically, and colour vision also is reduced.

4. Hysterical Amblyopia is a very characteristdc affection, and oonsidts of a coneoi-
tric retraction of both fields, though most extreme on the same side as the hemiao-
sesthesia, by which it is almost invariably accompanied. The colour vision is also
aifeoted in a characteristic manner (see ante).

5. Neurasthenic or Retinal Asthenopia, a condition in which the patient erases to
be able to see after exercising the visual function for a time, is also unattended fay
changes in the fundi. The field of vision is also contracted, and temporary sootomata
appear on looking at objects.

6. Sudden and Copious Hosmorrhage — e.g,, from the stomach, bowels, utema, etc —
may produce amblyopia from deficient blood supply to the eyes, and possiUj to the
visual cortical centres. If it does not shortly clear up, optic neuritis is to be appre-
hended.

7. Exposure to blinding sunlight or electric light may cause acute amblyopia.
MoNONUCLEAB AMBLYOPIA. — It must be borne in mind that defective vision in

eye may be overlooked for many years, the patient thinking that he suddenly
blind when he has by chance shut the good eye on one occasion.

1. The remarks made above relative to optic neuritis and atrophy apply hera.
Local disecwes of the choroid or retina in the macular region produce central amblyopia
or central scotoma, often of one eye only.

2. Squint, from disuse of the squinting eye, produces amblyopia in chfldhood,
which is only very slowly, if ever, remedied. It happens thus : squint results in
double vision, and in order to see clearly the child unconsciously gets into the hahit
of neglecting the image produced by one of the two eyes, usually the squinting
After long habit this " suppression of image " becomes permanent. It would,
be more correct to say that the mind has lost the power of perceiving the image formed
in that eye, and can only be slowly educated up to it.

3. Astigmatism, Myopia or Hypermetropia in a very high degree (wh^e a dear image
may never have been formed on the retina) leads to defective vision, so that vhen a
full correction of error of refraction takes place, it is generally found tiiat the patieaf
cannot see. This probably arises from the fact that the retina has never recei^
the necessary practice or education for the appreciation of true images of objects.

4. OhUl.—A few cases appear to be produced by exposure to cold, which
acute retro-bulbar neuritis. Occurring for the most part in young adults, the
is fairly rapid, and accompanied by neuralgic pains in the same side of the head.
The affection is not usually serious, and recovers under the same means as those em-
ployed for paralysis of the facial nerve under like circumstances.

5. Reflex Amblyopia is certainly not common. It generally occurs only in one eye.
and is associated with a carious tooth. Sir Thomas Watson^ mentioned oases, sad
quite a number of cases have been collected by Tomes,^ in which the Mindness «ai
cured by the adequate treatment of a decayed tooth, and returned when this
gave trouble.

^ ** Lectures on the Principles and Practice of Physic,** 4th edition.
2 " A System of Dental Surgery," 4th edition, p. 674 et seq.

§ 612 ] DEFE0T8 OF PUPILS 869

Hemianopsia (hemianopia, hemiopia) means loss of sight in one half of the visual
field in both eyes, unaccompanied by changes in retina or disc. Four kinds are
deeoribed. but practically the first is the only one met with, and that is sufficiently
rare.

Homonymous or lateral Hemianopsia means loss of vision of the two left or right
halves (the conesponding halves) of the visual fields of oaph eye. Right lateral
hemianopsia means abolition of the right halves of the patient's visual fields. This
oorresponds to the temporal half of the left and the nasal half of the right retina
(see Fig. 162). Apart from its occasional occurrence in migraine, it is due to a gross
central lesion situated in some part of the visual path behind the ohiasma : (i.) in the
optic tract ; or (ii.) behind the corpora quadrige-mina — that is to say, the hinder
end of the internal capsule or the white fibres of the occipital lobe ; or (iii.) in the
visual centres of the cortex, situated in the occipital lobe. By employing Wernicke's
tost (§ 612) the first may be excluded. For the rest, the precise position and character
of the lesion can only be diagnosed by the accompanying symptoms. Cortical lesions
are usually associated with some form of aphasia, or with paralysis due to some
oerebral lesion. Lesions affecting the optic tract are syphilitic gummata or meningitis,
tubercle, and neoplasmata, softening and haamorrhage (rare). Tumours in the optic
thalamus, lenticular nucleus, and temporo-sphenoidal lobe may extend to or press
upon the optic tract. Other associated basal paralyses may aid the diagnosis.

The remaining variety {Heteronymotu Hemianopsia) is very rare. It may occur on
one side only. Temporal Hemianopsia is the loss of the outer half of each field, duo
to a blindness of the inner half of each retina. In the only cases on record it has
arisen from damage to the middle of the optic chiasma, or, rather, just behind or just
in front of the middle part. Pressure of a tumour, distended third ventricle, or
localised basal meningitis have produced it. It has been met with in some cases
of acromegaly with enlarged pituitary body. Recurrent attacks have been produced
by gummata. Nasal Hemianopsia is still rarer. It is usually unilateral, due to a
lesion situated in one optic tract just as it leaves the chiasma. Altitudinal Hemian-
opsia means loss of the upper or lower part of the fields, and if bilateral, is due to a
lesion involving the upper or lower art of the chiasma, optic neuritis, or sjrmmetrioal
cortical lesions.

NiOHT-BuNDKBSS (nyctalopia) is defective vision in dim lights. It is a feature of
retinitis pigmentosa, sjrphilitio retinitis, and it may be congenital (without fundal
changes). Eccentric contraction of the visual field supervenes, and finally complete
blindness. Acute night-blindness may attack those with defective general health
who have been exposed to very strong sun or artificial light, and in those cases the
prognosis is good.

§ 612. Defects in the Papils. — ^The iris comprises dilator fibres (supplied
by the cervical sympathetic), and constrictor fibres (supplied by the third
nerve) ; associated with these latter is the ciliary muscle, also supplied
by the third nerve. Each of these may be paralysed separately, and
paralysis of all three is known as ophthalmoplegia interna. The pupils
must be tested in regard to their shape, size, equality, mobility to light,
and mobility to accommodation. The patient should be placed opposite
a good light.

The shape of one or other pupil may be irregular, and this may bo due to old iritio
adhesions or the result of previous iridectomy. Coloboma iridis is a congenital
abnormality which sometimes exists without error in vision, consisting of a deficiency
of the iris, usually in the lower part, generally on both sides.

The mcibUity of the pupils must be tested both by the ligM and accommodcUion
reflex (see below).

. The average size of the pupils varies in healthy persons with the light and irrita-
bility of the retina and optic nerve.

Wien two pupils are unequal in size, and it is desired to ascertain which is the
normal one of the two, it may generally be inferred that the immobile pupil is the
abnormal one. Slight inequalities between the pupils may also bo observed in health.

870

THE NERVOUS SYSTEM

[fiu

Inequality of the pupils of the two eyes is a frequent symptom in gooend puil3ra3
of the insane, and an occasional one in tabes and migraine. It may exist obriovily
in any condition causing contraction or dilatation of the pupil on one side onlj (ne
below), as, for instance, in paralysis of one third nerve causing dilatation or panlyw
of the cervical sympathetic causing contraction.

The Mobility of thb Pupils to Light. — In testing the light reflex, both eyn
should be covered for half a minute, and each uncovered in turn opposite to a bright
light, which makes the pupils contract. In a good light the iris can sometiiDei be
observed to contract and dilate rhythmically, a phenomenon which is c«Ued iU'ppti.
Its clinical significance is unknown. The pupU light reflex depends on ihe integritjof
the retina and the following tract (Fig. 162), the optic nerve (o), the chiasniA (r). optic
tract (0, to the corpora quadrigemina {cq). Those last-named nuclei (c^) ue con-
nected, by means of Maynort's fibres (m). with the nuclei of the third nerves (111).

situated in the floor of the mjk-
duct of Sylvius. The fibres of the
third nerve, through the long or
short ciliary branches, oondoct coo*
traoting impulses to the sphincter
iridis.

Loss of Light Reflex (light irido-
plegia) may be produced by a km
situated anywhere in these sSenst
or efferent tracts, (i. ) In tabes tbe
pupils may be unequal, unduly eoo*
tracted, or fail to react to ti^ or
accommodation, but the ehasge
most oommonly met with b tfae
Argyll-Robertson pupil, whieh ii
Loss of reflex to Light, thosgk
Acting to Accommodation, lis
phenomenon, met with ocoukb-
ally in other oonditions. indicslH
a partial damage, involving citfe
of the optic tracts or Maywrt'i
fibres, (it) Ato>phyof bothoptii
nerves, (iii.) Destructive ksiw
of the third nerve or its vMkm-
(iv.) General paralysis of the in-
sane. The light reflex is present^
in blindness of central origin, b
unilateral optic atrophy, when tbf
sound side is uncovered, botk
pupils contract (consensual contraction), but the pupil on the affected side <i«
not contract when the affected side alone is uncovered.

Wemicke^s pupil reflex assists one to determine the seat of a lesion in a caw «
hemiopia. Hcmiopia may be due to a lesion (i. ) of the optic tract between the chii»»
and corpora quadrigemina (see Fig. 162) ; (ii.) of the optic fibres between the cf lai
the occipital cortex ; or (iii.) of the occipital cortex. If the lesion be in the optic tntt,
the light reflex is lost, but if behind the cq, a beam of light thrown-direcUy on the btiud
half of the retina by the concave mirror of the ophthalmoscope produces contrsct*
of the pupils. A little study of Fig. 162 will make this apparent.

MoBiLiry OP the Pupils to Accommodation. — Whenever the eyes converge »
the patient looks at a near object, the pupils contract. Ask the patient first to krt
at a distant object, and after observing the pupils, tell him suddenly to look at ty
tip of your finger, held 6 inches in front of his face. This is really a roaotion to «*
vergonce of the eyes. Loss of power of accommodation depends on paralysis or ^?***
ness of the ciliary muscle (cycloplegia) usually associated with paralysis of the spbine^
of the iris. Loss of mobility of the pupil to accommodation is one of the earliest ■='
most common symptoms in (i.) diphtheritic paralysis, and occurs on both sides. ^

Fig. 162.— Diagram showing Rbflsx Arcs concerned
in the Movements of the Pupil (Harixontal Plane).
— Of opUc nerves ; c, optic chiasma ; <, optic tract ;
rg, corpora quadrigemina; ///, third nerves and
nuclei ; m and /, Majmert's fibres communicating
between the third nuclei and the corpora quadri-
gemina. (Vertical plane Fig. 163).

|§ 612a, 6126] PARALYSIS OF THE CERVICAL SYMPATHETIC 871

is also seen in (ii.) belladonna poisoning, and (iii.) occasionally tabes and 6. P. I. It
is preserved in the Argyll-Robertson pupil {vide supra).

Ophthalmoplboia nrrsBNA is paralysis of the thres internal muscles of the eye
(the sphincter and dilator pupillsB and the ciliary muscle). The pupils are of medium
size, and immobile to light and accommodation. It constitutes an early symptom of
diphtheritic and sometimes syphilitic paralysis, in either of which it is due to toxic
affection of the oculo-motor nuclei. It is often associated with ophthalmoplegia
externa.

CHiio-SpiNAL or Skin Reflex is the dilatation of the pupil when the skin of the
neck on one side of a healthy person is stimulated by stroking, pinching, or faradisa-
tion, and is due to the stimulation of the dilator fibres contained in the cervical
sympathetic (see Fig. 163). The loss of this skin reflex may be observed occasionally
in tabes and 6. P. I., but is chiefly met with as one of the symptoms of paralysis of
the cervical sympathetic.

Contraction of both Pupils (myosis) may be caused by (i.) undue retinal irrita-
bility, which may ensue from overuse of the eyes, and from hypermetropia. (ii.) It
is also present in congestion of the iris from any cause, which possibly explains their
contraction in mitral regurgitation, (iii.) Various drugs, such as opium, tobacco,
cserine, or pilocarpin. (iv.) Tabes dorsalis, which is often attended also by loss of
the light reflex {supra), (v.) Gleneral paralysis of the insane is sometimes attended
by the same condition of pupils, the " pin-point " pupils — i.e., strong contraction with
sluggishness of movement, (vi.) Irritation of the third nerve as by pressure of
tumour or the early stage of all inflammatory or meningeal affections, or irritation of
the pupil contracting centre — e.g., hsemorrhage into the pons causes a state of coma
with contracted pupils, which may distinguish it from hemorrhage into other
situations, opium poisoning being excluded, (vii.) Paralysis of the cervical
sympathetic.

{ 612a. Iritif, inflammation of the iris, is manifested by (1) immobility, loss of
lustre, and exudation ; (2) pain (which may be absent in serous iritis), and dimness of
vision ; (3) adhesions between the iris and anterior capsule, revealed under atrcpin ;
(4) circumcomeal injection of the ciliary vessels, indicating hyperemia of the ciliaj^
body (irido-oyditis). Care must be taken not to mistake (on account of 4) this
disease for conjunctivitis, because the treatment suitable for the latter will make
iritis worse.

The Causes of iritis are now known to be very numerous. Rheumatic, syphilitic,
oral sepsis, and many other toxsemic and infective conditions hitherto unsuspected,
may cause iritis. Syphilitic iritis is usually non-recurrent, but all the others are very
liable to relapse. Chill, bright light, and injury are determining causes.

The Treatment consists of reg^ular application of atropin drops (1 per cent.), dry
heat, and leeches to the temple. If attended by much pain, aspirin (gr. xv.) generally
gives complete relief in fifteen to twenty minutes. For chronic iritis dionin (5 pei'
cent.) drops thrice daily, along with atropin, may be tried. If total synechise form,
Iridectomy should be performed, to prevent secondary glaucoma.

f 6126. Paralyiit of the Cervical Sympathetic causes contraction of the pupil, usually
on one side only. The cervical sympathetic conveys dilator fibres to the iris, which,
arising probably in the floor of the aqueduct, pass down the spinal cord to the cilio-
spinal centre (Fig. 163), which is situated at the junction of the cervical and dorsal
regions, thence outwards by the rami communicantes to join the sjrmpathetic ganglia
in the neck, and upwards along the carotid and cavernous plexuses to be finally dis-
tributed to the eyeball along with the ophthalmic division of the fifth. The symp-
toms of paralysis of the cervical sympathetic are (i.) contraction of the pupil of that
side, with absence of dilatation of the pupil on shading the eye or the instillation of
cocaine ; (ii.) abolition of the cilio-spinal reflex {vide supra) ; (iii.) some recession of the
eyeball, so that the eye looks smaller than its fellow ; (iv.) slight drooping of the upper
lid on that side due to paralysis of Miiller^s unstriped muscular fibres ; and (v.) absence
of sweating on that half of the head and neck, and perhaps the upper extremity of that
side, even after the administration of pilocarpin or other sudorific.

Paralysis of the cervical sympathetic may arise from the pressure of an aneurysm
of the aorta or other intrathoiacic tumour, from exostoses or other tumours in the

872

THE NERVOUS SYSTEM

[§«1»

neck, or from injury or disease of the spinal cord below the medull*, bat above the
second dorsal segment.

Dilatation ov Both Pupils (Mydriasis) may be prodnoed by (i.) <^ eondition ol
myopia, (ii.) The pupils are larger in childhood, (iii.) Oertain drugs, a^opin.
duboisin, cocaine, (iv.) Neurasthenia and other exhausted states of the nervouB
system — e,g., anaomia and typhoid, (v.) During an apoplectic or epileptic attack
the pupils are dilated, and in such states it forms a valuable means of diagnosis, for
the symptom cannot be feigned, and is present in all the genuine cases of coma,
excepting from hsemorrhage into the pons, (vi.) In diphthoritio paralysis, bilateral
dilatation of the pupil and loss of power of accommodation (oydoi^egia) is an early
and constant symptom, and may be accompanied also by complete ophthalmoplegia
interna (dilator and sphincter iridis and ciliary muscle), (vii.) Paralysis of the third
nerve (destructive lesions of the trunk or its nucleus), a condition which gives rise to
four symptoms : Dilatation of the pupil, loss of accommodation, external strabismus

Corpora

quadrigemina.

Medulla.

From Post, roots.

Fig. 163. — Diagram of the Kbflbx Abos conoerned in Movbkbnts of thb Pupil (vertteal plmae).—
O, nacleus of optio nerve in corpora quadrigemina ; o', opUo tract (939 Fig. 182) : ///, nueleBf
of third nerve (the upper part only being concerned in the pupillary movementa) ; e, oon-
strlctor branches accompanying third nerve ; 2>, dilator cilio-spinal centre ; «, dilator llbrilt
from cervical sympathetic accompanying the ophthalmic division of the fifth ; R.O^ Bami
communicantes of sympathetic throo^ anterior spinal roots of eighth cervical nerve.

(producing diplopia), and ptosis, (viii.) Irritation of the cervical sympathetic as by
spinal growths or meningitis, (ix.) Certain psychic emotions such as fear and deep
inspiration dilate the pupil. Unilateral recurrent mydriasis often precedes mental
derangement.

§ 618. Ocolo-motor Defects. — ^The external muscles of the eyeball (as
distinct from the internal or involuntary muscles of the iris) are six in
number, and they are supplied by three cranial nerves : External rectos
(VI. nerve) ; superior oblique (IV. nerve) ; internal, superior, and inferior
recti and inferior oblique are supplied by the III. nerve (which alao, it
will be remembered, supplies the levator palpebrsB, the contractor fibres
to the iris, and the ciliary muscle of accommodation). It follows tiierefore
that :

§ 618 ] OOULO'MOTOR DEFECTS 873

Complete paralysis of the third,
nerve is attended by

' Ptosis ; external strabismus ; pupil dilata-
tion and immobility ; loss of aooommoda-
tion ; inability to move eyeball inwards
or upwards, and only imperfectly down-
wards ; eyeball slightly protruded ; crossed
diplopia.
Paralysis of the sixth nerve is ( Internal strabismus ; inability to move eye

attended by 1 outwards ; homonymous diplopia.

Paralysis of the fourth nerve is j Slight deviation of cornea upwards ; homony-
attended by y mous diplopia on looking downwards.

Defects in the ocular muscles are revealed (1) by defective movements

of the eyebaU ; (2) by squmt ; (3) when the defect is only slight, by double

vision (diplopia) ; (4) by ophthalmoplegia externa ; or (5) by nystagmus.

The first question to answer is which of the muscles is affected ? The

second question relates to the position and nature of the lesion.

(1) The movementf of the eyeball« may be tested in simple cases by fixing the
patient's chin with one hand and asking him to follow with lids eyes your other hand
moved slowly inwards, outwards, upwards, and downwards. Notice any deficiency
of movements, jerkiness, or nystagmus. One eye may be tested at a time. The
power of convergence should also he tested by asking him to look steadily at the tip
of your finger while it is moved from a distance of 18 inches up to near the tip of his
nose.

Deficient movement of the eyebaU — indicates paralysis of

outwards external rectus — sixth nerve.

inwards internal rectus — ^third nerve.

downwards i * V**"*^ rectus — third nerve.

\superior oblique — ^fourth nerve.

downwards and outwards . superior oblique — ^fourth nerve.

(2) Squint, or strabismus, is a want of parallelism between the two visual axes.
It is called convergent when one eyeball looks inwards, and divergent when one eye looks
outwards. In children it is mostly due to some error of refraction — ^hypermetropia.
with concomitant internal strabismus (the commonest in children), or myopia, with
external strabismus, or defect in the fusion faculty. In adults, squint is more often
due to definite paralysis of an ocular nerve, and the matter is of much greater signifi-
cance (see below). In oonoomitant squint, the affected eye follows the sound eye
with equal defect in all directions, that being the reason why it is called ** concomitant "
squint. Each eye, when the other is covered, moves perfectly in aU directions, but
when examined together, the squint is present in all positions of the eyeball, especially
when the eye is looking straight forward, which is the position of rest for all the healthy
muscles. The defect of parallelism remains the same in all positions. Pabalytio
squint appears most markedly when the eye is moved into that position which neces-
sitates the use of the paralysed muscle. Diplopia is present in paralytic, but not in
concomitant, squint.

To examine for squint and to detect whether it is due to paralysis or spasm, and which
b the affected muscle, the patient is told to look at an object straight in front of him,
that being the normal position of the eyes at rest, and to fix some object. The eye
with which he fixes is the normal eye. The deviation of the affected eye from the
middle line is known as the " primary deviation." Now partially cover the sound
eye and let him fix with the affected eye. The sound eye will be found to deviate
('* secondary deviation "). In concomitant squint the primary and the secondary
deviation are equal, but in paralytic squint the secondary exceeds the primary. The
oblique position of the head affords a valuable hint as to which muscle is paralysed.
Several rules are given in books, and the student can, if he likes, work out the direo-
tion in which the patient would naturally look to compensate for the faulty position

874

THE NERVOUS SYSTEM

[§«U

of the eye. But he will find that the patient unconscioualy turns his ft^ce, or rather
his chin, towards the side of the weak or paralysed musde.

(3) Diplopia, or double yision* is Uie most delicate test for sli^t weakness or
paralysis of one of the ocular muscles, even when the weakness is too slight to ^VMliiee
any discoverable defect in the movement or position of the eyes. To detect which is
the affected muscle, hold a pencil vertically in front of the patient, and move it rapkUy
to the right, to the left, and in various directions, and ask him whether he can see
two pencils in any of these directions. The weakened muscle is on the same side as
the direction in which the dofible vision appears. But to detect accurately which eye
and which muscle is in fault, further procedures may be necessary (see below).
Erroneous projection — t.e., error in judging the distance of objects — and vertigo
(due to the same cause) are invariably associated with diplopia. The false image
which is seen by the affected eye is generally hazy and less distinct Uian the tme
image seen by the sound eye. Diplopia may be homonymous or crossed. In simple
or homonymous diplopia the false image lies on the same side as the affected eye ; in
crossed diplopia the false image lies on the side opposite to the affected eye. Paralysis
of the external rectus causes homonymous diplopia, paralysis of the internal rectus
causes crossed diplopia.

Method of Delecting the Affected Eye and Paralysed Musde. — Place a red ^aes before
the patient's left eye, and place a candle before him in a dark room, on a level with his
eyes, and about 3 yards distant. Suppose that it is found that the red imagw over-

Sup. RecC,

Inf, Rect,

Rtghc
SiqxRecC,

Inf.

.ObL

*
%
%

ObL

\
%

$
$

I
I

%
%
%

RighC
Inf.RecC.

Sup. Obi.

8i4p.mL.

Fig. 164. — Werner's Diagrams for detecting which is the affected musde hi cases of di^iloiia.

laps, or is a little to the left of the white image, and both images are on the same leveL
To determine which muscle is affected the candle must be moved to the right and to
the left, and we must notice in which direction the distance hettoeen the images freeosMf
increased. Suppose that on moving it to the right the image approaches till only
one candle is seen, and on moving to the left, the distance between the true and
images increases. Bearing in mind the rule that the weakened muscle is on the
side as the direction in which diplopia increases, it is evident that either th» left
external rectus or the right internal rectus (which turn the eyes to the left) is afeotcd.
Ask then on which side the red image appears. If on the left of the white image,
homonymous diplopia is present ; therefore the left external rectus is the paralysed
muscle. If, however, the red image is to the right of the white image, crossed diplopia
is present ; therefore the right internal rectus is the paralysed muscle. Paralysis of
the superior and inferior recti, and of the superior and inferior oblique, give rise to
vertical diplopia. The former causes crossed diplopia, the latter homonymous diplopia.
Loss of motion upwards is due to paralysis of the third nerve ; loss of motion down-
wards may be due to paralysis of the inferior rectus (third nerve) or the saperior
oblique (fourth nerve). Werner's diagrams (Fig. 164) simplify the detection of the
affected muscle in vertical diplopia. The black lines in the diagrams represent the
true images, the dotted lines the false images. The dotted lines extend above and
below the white lines, indicating that the false images are higher and lower than the
true images. The names of the muscles in the upper and lower part of the

i 818 ] OOULO-MOTOR DEFECTS 876

indicate that the diplopia is caused by upward and downward movements respectively
of the eyes when these muscles are affected. Thus, for example, in paralysis of the
right inferior rectus an analysis of the diagram shows that (1) the diplopia occurs with
downward movements of the eyes ; (2) the diplopia is crossed, the false being to the
left of the true image ; (3) the false image has its upper part inclined towards the
true image ; and (4) the false image lies lower than the true one. With the oblique
muscles it must be remembered that the superior oblique moves the eye downwards,
and therefore the false image due to the paralysis of the superior oblique appears on
moving the eyes downwards. By remembering the diagrams it is comparatively
simple to diagnose the paralysed muscle causing a diplopia.

MoNOCXTLAB DIPLOPIA is rare. It is recognised by the persistence of the symptoms
when one eye is completely closed. The symptom, which should be carefully verified,
may arise in some defects of the media or the retina, and in some central or functional
disorders.

The Pofiiion and Hatore of the Lesion in Ocular Paralysis is the next question to con-
sider, after having ascertained which muscle is affected in a case of a paralytic squint.

The concomitant squint of children in about 90 per cent, of the cases is due to hypcr-
metropia or some other error of refraction, or to a defect in the fusion faculty, and
when these are remedied the squint frequently disappears. It is only rarely due to
some congenital weakness of a muscle, or to a nuclear lesion like that of anterior
poliomyelitis, and occasionally to intracranial lesions like those met with in adult life.
In adults, however, ocular paralysis assumes a much graver significance. Here we
have to do with a gross or dynamic lesion involving (a) the nerve trunk of the third,
fourth, or sixth somewhere in front of the medulla, or (6) the nuclei of these nerves
in the pons or medulla, or (c) the cortex cerebri or motor fibres passing thence to the
ooulo-motor nuclei.

(a) Lesion of a nerve trunk is the most frequent cause of paralytic squint or diplopia
in adult life. In these cases we often find paralysis of a single nerve or a single muscle.
There is never any conjugate paralysis (see below) with lesion of a nerve trunk. Of
single muscles the external rectus is the one most commonly involved, on account of
the long course of the sixth nerve within the cranium. It may, indeed, be affected
on one or both sides simply by increased intracranial pressure from a distant tumour
or an acute meningitis. Other ocular nerve lesions are due to syphilitic or other
neuritis, pressure by syphilitic or other growths in the orbit, pituitary fossa, or base,
aneurysm of the carotid or thrombosis within the cavernous sinus (with involvement
also of the second and fifth nerves), or extravasation of blood after injury to the base.
Acute peripheral neuritis of all the ocular nerves is rare, but sometimes is seen with
alcoholic neuritis. It causes ophthalmoplegia, which is only differentiated from
ophthalmoplegia of nuclear origin by the absence of other head symptoms and the
presence of peripheral neuritis elsewhere.

(6) Nuclear Lesions. — ^The third nerve has a long nucleus in the floor of the aqueduct.
The upper or anterior end of this nucleus probably controls the pupil and accommoda-
tion, then in order the levator palpebrsB, internal rectus, superior rectus, inferior
oblique, and lowest of all, the inferior rectus. Immediately below this comes the
fourth nucleus, and below the latter the sixth nucleus in the floor of the upper part of
the fourth ventricle. Sudden and acute nuclear lesions are rare in these situations,
but chronic degenerative lesions are met with. The commonest result of nuclear
lesions is ophthalmoplegia externa (see below), caused by progressive involvement of
all three nuclei, and another instance is met with in the loss of light reflex in tabes
dorsalis, when the upper end of the third nucleus is affected. The simultaneous onset
of paralysis of the third nerve and hemiplegia (including the face) on the opposite
side points to a lesion in the cms cerebri. A lesion of the sixth nucleus of one side,
such as softening, has two peculiarities in which it differs from sixth nerve trunk
lesions, (i.) Conjugate ocular paralysis results, and both eyes are deviated aivay
from the side of the lesion by the unaffected muscles. This is due to the paralysis of
the external rectus on the side of the lesion being associated with paralysis of the
internal rectus of the other side. This is probably explained by the existence of com-
missural fibres connecting the two nuclei which are so frequently associated physio-
logically, (ii.) In some cases where the lesion is a little more extensive the entire

876 THE NERVOUS SYSTEM [ % «11

facial nerve of the same side is also paralysed, since the fibres of this nerve twine round
the sixth nucleus.

(c) Cerebral or supra-nudear lesions never paralyse sin^e muscles as do lesaons at
the base of the skull involving the ooulo-motor nerve trunks. Cerebral lesions always
take the form of a conjugate deviation of the eyei and head, the neck mnsdes. whieh
are so closely associated with the eye muscles in turning the head, being also involved,
and such lesions are attended by hemiplegia or other evidences of a cerebral leskm.
There is one spot in the cerebral cortex just in front of the upper end of the Rolandic
fissure, which, when stimulated, causes conjugate deviation of the head and eyes to
the opposite side. An irritative lesion in this situation, or anywhere in the course of
the fibres between this and the oculo-motor nuclei, will cause deviation, as already
pointed out, away from the source of irritation (!). But destructive or paralytic lesions
(which are more frequent) in this position cause deviation totoards the side of the lesion.
from the unopposed action of the unaffected muscles. For instance, hemiplegia doe
to cortical hsBmorrhage (an irritative lesion) is often attended during the first few
days by transient conjugate deviation of the head and eyes to the opposite side. In
lesions at a lower level, as in certain rare focal lesions situated in the pons,^ the above
rules as to the direction of the deviation are reversed, and the deviation is apt to
be of a more lasting character. Destructive lesions cause a deviation of the eye or
eyes and head aioay from the lesion. These are interesting examj^es of associated
paralyses (paralyses of muscles physiologically associated) due to cerebral lesions.

(4) Ophthalmoplegia externa means total paralysis of all the external muscles of
the eyes, the gaze being fixed and the eyes being motionless ; and since partial ptosis
is generally present at the same time, the patient has a sleepy expression, which is
very characteristic. It may occur alone, or associated with ophthalmoi^egia interna.
Acute ophthalmoplegia is due to inflammation or hsemorrhage involving the na<dei,
and is met with in diphtheria, diabetes, influenza, and lead poisoning. The duonie
form comes on so gradually that the patient may not have noticed it excepting by
the continual necessity of moving his head to look round. It indicates a chronic
degeneration of the ooulo-motor nuclei, generally of syphilitic, diphtheritic, or otlier
toxic origin. External and internal ophthalmoplegia may also occur, eath^ alone
or together, in some spinal lesions, such as tabes and bulbar paralysis, and in some
cerebral diseases involving the cranial nuclei. Weakness of the orbicularis palpe-
brarum (supplied by the facial) is often met with in cases of ophthalmoplegia externa,
and this is an interesting fact when we remember that the fibres of the facial nerve
wind round the nucleus of the sixth.

(5) Vyitagmas is a rapid involimtary oscillation of the eyeballs, usually from side
to side (lateral nystagmus), occasionally in a vertical direction (vertical nystagmus),
or in a circular direction (rotatory nystagmus). Both eyes aro usually involved,
though each eye should be separately examined. The movements may be constantly
present, but slighter degrees can only be brought out by causing the patient to follow
your finger or a bright object to the extreme left or right. Very slight nystagmus can
be discovered by direct ophthalmoscopic examination, when the image of the fundus,
becoming magnified about fifteen diameters, shows the slightest movements of the
eyeball. If so, it indicates a weakness of the muscles on the side to which the eye
is turned at that time. The symptom is notably present in disseminated sclerosis,
cerebellar tumour, and Friedreich's disease, and in tumour involving the corpora
quadrigemina, or one side of the pons. It occurs also with meningitis, thrombosis
of the sinuses, and cerebral softening in various situations. It may be an indication
of corneal, lenticular, retinal, or choroidal defects, especially when these start in
infancy. Sometimes it is congenital, especially in albinos. It is also met with in
miners, compositors, ironfounders, and those who work at close quarters, or in a
strained position with deficient light. ^

The Prognosis and Treatment of oculo-motor defects aro those of their causal con-
ditions. A large proportion of them are syphilitic in origin, and therefore amenable

^ See a case recorded by Dr. A. Hughes Bennett and the author in .^reitfi, 1889-
1890, vol. xii., p. 102.
a Snell, BriL Med. Joum., 1896, vol. i., p. 1503.

§ 614 ] OPHTHALMOSCOPIC DEFECTS 877

to treatment. In general, recovery is more probable in nerve trunk lesions than in
ohronio nuclear conditions. Ophthalmoplegia interna may remain stationary for
many years. For chronic oases counter-irritation and galvanism (applied through
the nurse's fingers over the eyelids) may be tried.

§ 614. Ophthalmofoopic Defeotf in the fundi oculorum. — The ophttudmof cope is an
instrument which is indispensable for the discovery of the affections of the retina,
choroid, and optic nerve. It is also of great use in general medicine. It is used for
three procedures : Indirect ophthalmoscopy, direct ophthalmoscopy, and (as men-
tioned in § 611) retinoscopy.

The ophthalmoscope has two concave mirrors, the larger one for indirect ophthalmos-
copy and retinoscopy. and a smaller one. which is tilted, and capable of being turned
on its own axis, for direct ophthalmoscopy. Bc^hind each of these is a hole, through
which the observer looks, and across which a series of lenses can be made to turn,
of different refractilo power. The room should be darkened, and a bright, steady light
placed just beside and behind the patient's head, on a level with his car, on the side
of the eye to be examined. An Argand burner is the best, either gas or oil. An
electric lamp is not so good, as the edge of the light is not straight. Take the ophthal-
moscope in your right hand and correct your own error of refraction (if any) by rota-
ting the appropriate lens into the hole behind the mirror through which you will
look. It makes it easier for a begiimer even with normal sight to use a + 1 lens.
If the patient is sitting in a chair, make him sit up (not backwards), with his head
slightly forwards, about 18 inches or 2 feet away from your own. First learn
to reflect the light steadily into his pupil, previously dilated with a 1 per cent,
solution of homatropin. Tell the patient to look away into the distance over your
shoulder.

The next step for indirect opTUhalmoscopy is to interpose between your eye and that
of the patient the convex lens. This lens should be of 2^ inches focal length, and
should measure at least 2^ inches across. This lens should be held about 2 inches
from the patient's cornea, between the thumb and index of your left hand, while the
little finger rests upon the patient's forehead. You can only find the correot position
of the lens by moving it backwards and forwards until a clear image of some retinal
vessel is obtained. TAe image of the retina seen is an inverted one.

There are three parts to be examined : (i.) The optic disc, which is seen by telling
the patient to look in the direction of the tip of your left ear for his left eye, and vice
versa, (ii.) The peripheral parts of the retina may be examined by the patient turn-
ing the eye as far as possible in various directions, (iii. ) The macular region is situated
two disc breadths to the outer side of the disc, and is brought into view when the
patient looks at the hole in the ophthalmoscopic mirror, or slightly to the side of it
when the light is too strong for him to bear.

Direct Ophthalmoscopy is conducted with the patient placed as before, but your head
is moved up tpiite close to the patient's eye, so as to look straight into it, as in Retinos-
<^Py (§ 611). Change the mirror on the ophthalmoscope for the smaller tilted one
spoken of above, and rotate it on its own axis, so that its prominent fonvard edge
will be next to the bridge of the patient's nose, the lamp being on the patient's right hand
for his right eye, on his left hand for his left eye, and always at the level of his ear.
First adjust the ophthalmoscope accurately to your own eye (right for examining
the patient's right eye, and left for his left), and get the handle flat against your
oheek. Then tilt your head a trifle sideways close to that of the patient, and tilt his
head slightly the other way to avoid his breath. If the fundus is not illuminated,
shift the lamp or the angle of the mirror, or your head, until the red glow from the
fundus is seen through the little hole in the mirror. Now, to get a good image, you
must completely relax your own accommodation. Herein lies the difficulty, but if you
imagine that you are looking away at some distant object, you will by degrees acquire
this necessary condition. The image, in direct ophthalmoscopy » is always an erect one
and magnified, and therefore the different parts of the fundus can be more carefully
investigated in detail than by the indirect method. To see the disc you should look
obliquely inwards when the patient is looking straight in front of him, and the other
parte of the retina may readily be examined by the patient moving the eyes slightly
in different directions.

878 THE NERVOUS S Y8TEM [ { 114

The (ypiic disc should be examined as to its shape, its borders, its colour, its TeflBeU,
and its level. Normally the diso is slightly oval or cironlar, with a dearly defined
border, especially at the outer edge. It appears oval in astigmatic eyes. The cdcmr
of the diso is a rosy vermilion, but paler than the rest of the fundus. The vendi
curve from the centre, and then lie flat. Arteries and veins go together, bat the
arteries are narrower (two-thirds) than the veins, a trifle paler, and have a broader,
more continuous light stripe running along the centre. Normally the arteries do not
pulsate, but the veins, curiously enough, may do so. Pulsation in the arteries may
indicate (i.) increased intraocular tension or (ii.) aortic regurgitation. The Uvd u
important, but a little difiicult to gauge. The level of the disc is beet detected by the
direct method of ophthalmoscopic examination. If when thus using the ophthalmo-
scope the retina can be seen clearly without the aid of any lens placed in the mirror
hole, but the disc cannot be seen clearly without the aid of the lens, it mast be at »
different level. If a weak — glass is necessary to see the disc under the«e circum-
stances, then the disc must be clearly behind the retinal level (cupping). If, oo the
other hand, a weak + lens is necessary, then the disc is on a level anterior to the retina
(swelling). One can even gauge the amount of swelling or cupping in this way, for
roughly each 3 D. = 1 mm. of swelling or cupping. Thus, supposing it is neccMuy
to use 1 D. to focus the retinal vessels precisely, and 4 D. to focus the disc, then there
must be 3 D or 1 mm. swelling or cupping. This is an accurate method of measoring,
provided the observer is able to thoroughly rdax his own accommodation.

Two important Morbid Ohangei in the Opftic Disc are met with (in addition to
hyperemia and anaemia) — optic neuritis and optic atrophy. In hffperiBmia, the ookmr
of the disc approximates more nearly to the rest of the fundus. Active hyperamia
may be present in hypermetropia. Passive hypersamia is present in optic neoritii
and in the venous congestion secondary to cardiac or pulmonary disease. Autmia
of the optic disc is almost indistinguishable from an early stage of atrophy. It
requires some experience to detect the difference in these delicate shades.

Optic Venritii, or so-called Paiiillitis, is inflammation of the optic nerve at its
entrance into the globe, and is evidenced, in its typical marked form, by blurring of
the edges, swelling, increased redness and vascularity of the disc. The arteries
become narrower, and the veins are enlarged and tortuous, the vessels curving over
the oedematous edge. The arteries, moreover, may appear broken here and there,
as they are hidden by the oodema. In the eariy stage the diso has simply a fluffy
look, and then the upper and lower edges only are blurred, a condition which is only
apparent when the direct method is employed. These inflammatory changes may
gradually subside, but more commonly they go on to " consecutive " atrophy. It
should be remembered that the power of vision may be undisturbed, even when there is
oonsiderable papillitis, though the visual field is usually diminished in some degree.
Disturbance of vision is generally more marked as the acute stage subeidee. Early
and progressive loss of vision points to damage of, or pressure on, the chiasma, and is
such a case the pupil is dilated and immobile to light. In optic neuritis with preserva-
tion of vision the pupils react to light. Double optic neuritis is very stron^y suggestive
of intracranial disetkse, and especially (i.) cerebral tumour, in which it is present at
some time in about 80 per cent, of the cases. It is lees oommon in cerebral absees
and in cerebellar and other diseases in the posterior fossa, and is rare in cerefacal
hemorrhage and embolism, (ii.) Increase of pressure from any other oauss — cf.
tuberoulous meningitis — though it may be at a late stage. It is not oonunon with
simple acute meningitis. It is occasionally present in the cerebral form of disseminated
sclerosis. Syphilis may produce papillitis in several ways. Various toxic conditumt
of the blood may produce optic neuritis, chief among which is renal disease giving riie
to a special form (see below). Plumbism and anemia are occasional causes, alio
influenza, rheumatism, typhoid, and scarlet fevers. Sudden suppression of tfar
menses has been known to cause optic neuritis.

Unilateral Papillitis indicates disease at the back of the orbit — e.^.. tumour of
gummatous infiltration, cellulitis, or periostitis.

Opftic Atrophy — that is, atrophy of the optic diso — is characterised by exoenive
pallor of the disc, a very sharply-defined outline, and smallness of the vessels. In
marked casee sight is completely lost, excepting, perhaps, for light. Optic atrophy

§ 616 ] OPHTHALMOSCOPIC DEFECTS 879

may be " conaeeulive " to a severe papillitis. It may also Buoceed embolism of the
central artery, retinitis pigmentosa, 83rphilitic choroido-lretinitis, or pressure or injury
of some part of the optic nerve or chiasma (as when blindness of one eye follows a
blow on the head). Primary atrophy, part of a sclerosis of the optic nerve, usually
arises in connection with some spinal lesion, such as tabes or disseminated sclerosis.
Primary optic atrophy without other cranial symptoms should always make us
suspect tabes. It is seldom possible to differentiate primary and consecutive atrophy
without a knowledge of the clinical history. Optic atrophy may supervene on toxic
amblyopia.

Bettnitii, inflammation of the retina, is evidenced by a smokiness or haziness and
loss of transparency. It may be either diffuse or patchy. Pigmentary deposits in
the retina are superficial to the vesseb, and appear as a network. In the choroid,
pigmentary deposits are beneath the vessels, and occur for the most part in rings or
blotches. Choroidal atrophy appears as pale or white patches, with rings or spots of
pigment in or near them. Only a few of the chief forms of retinal and choroidal
disease can be mentioned here.

Albnminnrio Betinitif is really a neuro-retinitis, consisting of three elements,
(i.) Papillitis (see above) ; (ii.) hsemorrhages into the retina, usually most plentiful
towards the disc ; and (iii.) fine white shining spots near the macula, and larger ones
on the retina near the disc, with clearly -defin^ margins, supposed to be due to a kind
of fatty degeneration of the retinal structures. One or other of these is sometimes
wanting, but in its typical form this kind of retinitis is sufficiently distinctive to diag-
nose renal disease without examining the urine. It may occur in any form of renal
affection, but is frequently associated with granular kidney. H^smorrhaobs into
the retina and choroid are met with as dark red patches. They accompany any severe
retinitis or papillitis, are met with in albuminuric retinitis, also in pernicious anaemia,
leuoocythsBmia, pyiemia, ague, scurvy, and other purpuric conditions. Retinal
hsemorrhages are sometimes met with in elderly gouty persons with degenerated
arteries. Embolism of thb Cektbal Abtbry of the Retina occurs most ^quently
in the course of cardiac disease, especially in disease of the aortic valves, and in acute
and ulcerative endocarditis. It is known by the sudden occurrence of blindness
in one eye in a case of cardiac disease. On examination, the retinal vesseb are found
empty, and a peculiar round, cherry-red spot is soon in the macular region. The
disc is pale. Rbtikitis Pigmentosa is characterised by pigmentation in bone —
corpuscular-like patches. The disc is greyish-yellow. Night blindness is the chief
symptom, and the disease starts in childhood.

Ohoroiditif Diiieiiiinata (usually bilateral, though sometimes limited to one eye)
is frequently an evidence of syphilis (hereditary or acquired), in which disease it may
arise from three months to three years after the commencement. On examination,
discrete, white, atrophic patehes, with irregular black edges, are found scattered over
the fundus, moH marked at the periphery. Atrophig Patches in the Choroid may
be found in the central region in myopia or as the result of previous choroidal hsamor-
rhages, or after the absorption of tubercle. Tubercle of the Choroid appears as
yellow, roundish, ill-defined spots, one-third to half the size of the disc, situated
near the disc, and unaccompanied by other choroidal changes. They may thus be
distinguished from choroidal atrophy, where the spots are white, irregular, and
pigmented. They appear in general tuberculosis, and in tuberculous meningitis,
though usually late in the history of the case, and are therefore not of great diagnostic
value.

§ ns. The Fifth Nerve supplies sensation to the face, the sense of taste

to the tongue, and motion to the muscles of mastication.

The fifth supplies the face and forehead, the oral, nasal, and buccal cavities, the
oonjunotiva and sclerotic with sensaiion (see Fig. 165), the whole of the tongue with
the sense of taste ; and it carries — as we know by the effects of lesions of its nuclei or
trunk — ^trophic, vaso-motor, and secretory (to the salivary and lachrymal glands)
fibres. A motor root arises close beside it, and accompanies its lowest or third division
to supply several muscles (the temporal, masseter, two pterygoid, buccinator, mylo-

880 THE NERVOUS SYSTEM [ § CIS

hyoid, anterior belly of digastric, and tensor tympani). Looking upon the nneki
of the cranial nerves as continuations upwards of the anterior (motor) and posterior
(sensory) grey horns of the spinal cord, the sensory portion of the fifth nerve con-
stitutes the sensory nerve which corresponds to the facial nerve which is entirely
motor.

CLUsacAJL Ihybstigatiok. — ^The sensation of the areas above mentioiied can be
tested in the usual way. When it is lost, the patient in drinking feels only one-hilf
of the tumbler, and may imagine it is broken. The motor functions of the fifth are
tested by asking the patient to clench his teeth while you place the fingers on the
temporal muscles of both sides and then on the masseters. It may be inferred that
the pterygoids of one side are paralysed if on opening the mouth or projecting the
chin forward the jaw deviates towards one side — i.e., towards the paralysed side (by
the action of the unaffected pterygoids of the opposite side). Paralysis of the tensor
tympani produces a diminution of hearing for high notes. The function of iasie will
be considered below. This should always be tested in suspected lesions of the trunk
or ganglion of the fifth.

The Symptoma of destructive or paralytic lesions of the fifth nerve or nucleus oonsst
of the following alterations, according to the part involved : Aniesthesia (preceded,
perhaps, by severe burning pain) of the area supplied by the fifth ; loss of conjunctival,
palatal, and nasal reflexes on that side ; loss of secretion of lachrymal and salivaiy

/ I ••» - — \ s'^Mtpm'Oi^UtU branch

great ocdpUal ■/ • /\ '"\ \ S ■ ouriailo ctmporal branck

smaU occipUal \/ /9N y **^ \

(cervicalpUxu^y " A fm^^ -^-X- !^in^^OiUtal branch

greaC auricular In^ < ""* i

(cen^cal /rf^sjpu^i'- --r.. y^A^^ sf^inferior denial branch

/ Y ._/ "-> superfiOAMl cervical

\^ j (cervical jpUxus)

Fig. 166. — Nerves supplying Cutankoits Sbnsatioh to the HiAD.

glands ; loss of smeU, owing to the dryness of mucous membrane ; loss of
diminished masticatory power, and collection of food between cheek and jaw ; hemi-
atrophy facialis (§617) occasionally.

IrriteUive lesions of the fifth nerve give rise to facial neuralgia and hypenssthesia
or tender points. Irritative lesions of the Grasserian ganglion are attended also by
very serious trophic changes — cloudiness of the cornea, going on to perforation,
destructive panophthalmitis, herpes frontalis, or vesicles in other positions. And in
oases sloughing of the mucous membrane of the cheeks. Reflex irritation of the fifth
nerve may give rise through the facial nerve to twitohings of the faoe, or throo^ the
optic nerve to flashes of light.

Ledoiis of the Fifth. — (i.) Lesions of the cerebrum, involving the sensory
way of Charcot, imply facial as well as corporeal hemianissthesia, both of which
on the side opposite to the lesion, (ii.) Lesions within the pons, attended with
poreal hemiansssthesia, produce a " crossed " ansBsthesia, face on same side, body
on the other. Lesions, however, such as hemorrhage, softening, or tumour in th^
situation more frequently involve part of the widespread fifth nucleus than the
(iii.) Within the cranial cavity syphilitio meningeal conditions, caries of the
bone on the tip of which the Gasserian ganglion rests, tumours, aneurysms, and
rarely fractures of the base, produce total or partial paralysis of the fifth,
in the pituitary region, cavernous sinus, or orbit — e,g., aneurysm of the internal
carotid, or orbital cellulitis— damage the first division of the nerve, (iv.) OmUide lie

§ 616 ] SENSE OF TASTE 881

cranial capUy one or othor division may be paralysed by tunumra — ^tumours of the
parotid, for instance, extending into the spheno-maxillaiy fossa, and damaging the
second and third divisions of the nerve. The deep position of the fifth usually protects
it from injury, and neuritis is said to be rare. It is, however, to my mind very difi&>
cult to account for the fact that the branches of this nerve form the favourite seat for
neuralgia, and that herpes so constantly occurs, excepting on the supposition thai
those branches, or the nerve or its ganglion, are the seats of neuritis. The fifth nervo
is a frequent seat of reflex irritation from distant parts (Neuralgia, § 604). It is also
(he source of reflex irritation in oases of facial twitchings, cough, and other motor
spasms. Growths in the naso-pharynx (usually of a malignant nature) may give
rise to a very definite syndrome. They often start in the region of the Eustacldan
cushion, and by implication of the neighbouring structures they give rise to deafness,
deficient movement of the palate with asymmetry of the two sides when the palate is
at rest, and to severe pain in the course of the fifth nerve. The pain may be treated
without a suspicion of the true nature of the cause, and this in spite of the fact that
the nose has been examined. Such growths are usually epithelioma and seem to
affect especially men.

The Prognosis and Treatment of neuralgia of the fifth has already been dealt with
in § 604. The prognosis and treatment of the other lesions depend upon their nature.

§ 616. The sense of Taste should always be tested in suspected lesions
of the fifth, which is the nerve of taste. Powdered salt, sugar, and
quinine are necessary. The patient should put out his tongue and keep
it out till the end of the test. Having wiped the tongue, place on it a
minute portion say of powdered sugar, gently rub in, and ask " Is that
saltl" "Is it bitter?" "Is it sweet?" The patient can reply by
shaking or nodding his head. Citric acid may also be employed. A
weak galvanic current causes a metallic taste. Sweets and acids are
tasted best by the anterior part of the tongue, bitters by the posterior
part;

Tract of Taste (Fig. 166). — Between the tongue and the main trunk of the fifth
nerve, taste is conveyed by two separate and circuitous routes, (a) The chorda
tympani running in the tongue with the lingual branch of the third division of the
fifth collects taste fibres from the anterior two-thirds of the tongue (some say the tip
and anterior two-thirds of the edge). The chorda then joins the facial nerve just
above its exit from the stylo-mastoid foramen, and after running its well-known
course through the tympanum doubles back as the Vidian nerve from the facial to
Mockers ganglion, and thence to the second division of the fifth, (b) From the middle
and posterior part of the tongue taste fibres pass along the ^osso-pharyngeal nerve,
which they leave by Jaoobson's nerve to join the tympanic plexus, thence by the small
superficial petrosal and the otic ganglion they pass to join the second division of
the fifth. Some hold that the taste fibres reach the brain by the glosso-pharyngeal
nerve. After reaching the pons, the path of taste decussates, and reaches the pos-
terior part of the internal capsule of the opposite side, and is believed to terminate
in the cortex at the tip of the temporo-sphenoidal lobe.

The commonest Cause of loss of taste in the tip and edges is (i.) a lesion of the
faoial in the Fallopian aqueduct, as in middle-ear disease. (2) Loss of taste in the
posterior part of the tongue is met with in lesions of the third division of the fifth ;
of the anterior part in lesions of the second division, and of the whole of one side of
the tongue in lesions of the trunk of the fifth just outside the pons. (3) Loss of taste
of one-half of the tongue occurs in many cases of hemiansesthesia. whether of functional
or organic origin. (4) Disturbances of taste are frequent in influenza, diphtheria,
and some other acute specific disorders. (5) Taste is greatly aided by the sense of
smell. Flavours, such as those of cheese, wine, or roast beef, really consist of com*
pound perceptions of smell and taste. Consequently catarrh and many nasal diseases
are attended with impairment of taste.

882 TBE NSBVOVS SYSTEM [\m

Paragtuu (perverted tMt«)»nd bypersguas <inoi«Med senaibUil; to taste) tR iM
with w kur» to epileptic fits, in oonjVDotion with inanity, with hjilena, lad nme-
tim«e with middlo-ear dioeaao.

§ 617. The Facial Hwre (the seveath) is a purely motor nem supply-
ing all the irmacles of the Bcalp and face (except Hie levator palp^ne
superioris), the platysma, two small musclca of the hyoid bone and lit
stapedius; The facial and the sixth are more frequently involved wngly

Fta. IM.— Snrai oi TAsn uid ITnvi-SirFPLi oi Fiutb.— DU«nm to ihow boir Mti*
piMsloiu rtuti the fltth nsTTB m—t, and tha moCoi-fapply or Uw ptlata .— «. T. koM
of tha chonU tympuii ooDTtrinS tuta front t)w Up 4iid ildaa of tba tongne, lad T^
with tba llDgiUl bnndi ol (ba flflb, than Utrongh the fadal to Hsckd'* gancttoo {MK*
Itaanoa to tba leoaad dlviabn al (ha flltb. p, tolt palsta from which, and fraai Itii dn^
of tha tonsoe, twta flbtai pan thiongb the pharrnsail [denu (Fl to ]obi tlie tfoawpbvfi^
uidtb«iteathroiubtheoUamaglloil(o)IotbethiTd<liTliioiioftbeflIth. TbapaUlcltfef
■sen, ii aapplied by tha woeamy porUan of ths iplral MocMory thtoash Iha ncai-

than is any othei cranial nerve. The facial is also very frequently partik'
involved in cases of hemiplegia.

Anntomy of the Pioiii. Nbbvb (Fig. 107).— The nvdetu of the {soul
Bitnated in the floor of tba foortli Tentriole, just booeAth the moat pronuanl^
of the eminoDtta teres. Its lower end is in close proximity to the nncteud''
twelfth (hypoglossal), a fact which oorresponds to the close aasooistion betwof
mnsoles of the lips and those of the tongue. There is good reason to faelicTt :
the orbioularie oris is innervated from the tatclau of tile hypogloBsal (see EsE
Fatalyeia). Its upper end is dose to the dxth (abduoens] nucleus, around wiad
fibres onrvo aa they pass to the saperfiaial origin. The eortiad centre for the b«
sitnated at the lower end of the asoending frontal convolution, and this coatreii''
neoted with the facial ouoleus lArou; A Ihe inttmal cajuute, Henoe the fi^qoenc.' '■
which the lower h&lf of the face is aOeated in oaiea of hemiplegia. Th« ttaii i^
cross to the opposite side in the upper part of the pons, and appaiT on W

§ 617 ] FACIAL NEB VE 883

at the lower edge of the pons. The nerve then accompanies the eighth (auditory)
nerve to the internal auditory meatus. . At the lower end of the internal auditory
meatus the facial nerve presents a swelling (the geniculate ganglion), which gives off
three important branches. It then enters the aqueductus Fallopii, which curves
forward over the foramen ovale on the inner wall of the tympanum, then passes
dowD wards and out through the styloid foramen, and while traversing the parotid
gland breaks into its two main terminal divisions, the temporo-facial to the muscles
of the upper half of the face, the cervico-faoial to those of the lower half, the platysma,
the mylo-hyoid, and the posterior belly of the digastric.

The first and clinically most important branch of the facial is the great petrosal
(or Vidian) nerve, which joins the geniculate ganglion to Meckel's ganglion. Meckers
or tbo spheno-palatine ganglion is connected above with the second division of the
fifth, and the lower branches coming off from it supply the palate (Fig. 166). It
was formerly thought that these were motor branches originating from the facial,
bat clinical research shows that the great petrosal nerve is really sensory, and contains
taste fibres derived from the second division of the fifth, which join the geniculate
ganglion, pass along the facial trunk, and leave the facial trunk as the chorda tympani
nerve. It was Hughlings Jackson who first declared he had never seen undoubted
paralysis of the palate in association with lesions limited to the facial nerve, that the
palate is to a certain extent asymmetrical in most people, and that this fact had not
iiitherto been sufficiently allowed for. It is, moreover, a clinical fact which Gowers
bas insisted upon, that loss of taste is only associated with lesions of the facial nerve
fituated at some point between the geniculate ganglion and the styloid foramen.
Lesions of the facial nerve behind the latter point do not give rise to loss of taste.
!]!linically, it is of great importance to remember that the Fallopian aqueduct is
)ieroed by three structures, and through these holes inflammation may spread to the
acial nerve. The first contains a small nerve twig from the ^ial nerve to the
ttapedius muscle. The second contains an arterial twig from the tympanum for the
lutriment of the structures in the aqueduct. The third contains the chorda tympani
lerve which comes off from the facial \ inch above the stylo-mastoid foramen, and
masses forwards between the handle of the malleus and the stapes, turns downwards,
nd after giving a vaso-constrictor branch to the submaxillary ganglion, terminates
1 the tongue, which it supplies with taste fibres at the tip and along the anterior
wo-thirds of the margin.

In the Clinioal Investigation of cases of facial paralysis, as in other
isorders of the nervous system, the first step is to discover the position
f the lesion and then its nature. This is done by investigating first, the
luscles that are affected ; secondly, the condition of the hearing ; thirdly,
lie condition of the taste ; and fourthly, the electrical reactions.

The Symptoms of complete paralysis of the facial nerve (Bell's paralysis)
re (i.) an obvious one-sided alteration of the face which is pulled up away
•om the paralysed side by the unaffected muscles, the forehead and
leek of the paralysed side being smooth and expressionless, (ii.) The
itient cannot shut his eyes, or in slight cases he cannot keep them shut
hen we try forcibly to open them, (iii.) The comer of the mouth is
rawn np when he attempts to screw up the eyes, he cannot smile or show
s teeth. He cannot whistle, and the food collects between the cheek
id teeth, (iv.) The taste and (v.) the hearing may be affected in certain
sea (see below). Paresis of the palate used to be mentioned, but the
ilate is now known to be supplied by the spinal accessory. In the course

many months the affected side becomes drawn up by contraction of the
iralysed muscles (Fig. 168). Facial paralysis must not be confused with
imiatrophy facialis (see below).

882 THE NERVOUS S7BTEM II«17

Paragnsis (pervBrtod taste) and hyperagnuis (inoraMcd MndbUity to teste) •« mot
with fts aura to epileptic fita, in oonjunctioQ with inaanity. with hyatena. aiHl ioiiie-
timee with middlo-car diBetwo.

§ 617. The FadfJ Herre {the Boventh) is a purely motor neive aapply-
ing all the mnsclea of the acalp and face (except the levator palpebm
STiperiorU), the platysma, two amall muscles of the hyoid bone and the
atapediuB.- The facial and the sixth are more frequently involved aingly

™_ ]M — Bsnaa oi Tash tod ITKtTtSirpPLi or Piuim.— Diagram to ihcni bow U^ !■-
pnaaioiu reaoh UtB Wlh QwrB ■-., and tba motor-iDppI]' at ths palate — «. T, bnadM
at the oborda tympani ayanylag tart« from tha tip and aids of tha toosne, and nmuaf
witta tiN llnraial branch ol tbe atth, tbra Umngh U» tadal to Huckd-i luaUaii (10, aad
Ibmoo to ttw leoond dlvWon of the Htt*. p. aott pUata from which, i"'< f"" «- *— -
ol tha l«nEiw, taita ftbra paM Utron^ tba pbarrnsul plaiDKP) to Join tl
and tbsnea throngh tbe otin gaDgUon {0} to ttaa third diTUon of the ar»>
laen, to toppUad by the aeoanoiy portion of tha eplnal aooe«or; tb

than ia any other cranial nerve. The facial is also very frequently partially
involved in casea of hemiplegia.

Anatomy of the Facul Naiiv* (Big, 197).— Tho naeinu of the fa^ual nerve ■
Bituat«d in the Boor of the fourth ventriole, jiut beneath the most prominent part
o£ the eminentJa teres. Its lower end ia in close proximity lo the nnctena of tha
twelfth (hypogloBsal), a fact which oorreBpondB to the oloae association between tfce
masoles of the ILpa and those of the tongue. There U good reason to believe that
the orbioolariH oris is innervated from Uie nucittu of tbe hypo^oaaal (see Bnlhar
ParaWsis). Its upper end is close to the sixth (abdnoens) nncleOB. around vhioh its
fibres carve as they pass to the mperfioial origin, Tbe cortical centre for the face ii
situated at tbe lower end of the asoending frontal convolntion. aad this centre ia eoo*
neoted with the facial nuoleus Ihrtntgh the inlernal eapmie. Henoe the freqneney witk
which the lower half of the face is afleoted in oases of hemiplegia. The £m>*I Sbna
otoss to the opposite side in tbe oppar part of the pons, and appear on the iuitau.

S617] FACIAL NERVE 883

at the lower edge of the pons. The nerve then accompanies the eighth (anditory)
nerve to the internal auditory meatus. . At the lower end of the internal auditory
meatus the facial nerve presents a swelling (the geniculate ganglion), which gives off
three important branches. It then enters the aqueduotus Fallopii, which curves
forward over the foramen ovale on the inner wall of the tympanum, then passes
downwards and out through the styloid foramen, and while traversing the parotid
gland breaks into its two main terminal divisions, the temporo -facial to the muscles
of the upper half of the face, the cervioo-faoial to those of the lower half, the platysma,
the mylo-hyoid, and the posterior belly of the digastric.

The first and clinically most important branch of the facial is the great petrosal
(or Vidian) nerve, which joins the geniculate ganglion to Meckel's ganglion. Meckel's
or the spheno-palatine ganglion is connected above with the second division of the
fifth, and the lower branches coming off from it supply the palate (Fig. 166). It
was formerly thought that these were motor branches originating from the facial,
bat clinical research shows that the great petrosal nerve is really sensory, and contains
taste fibres derived from the second division of the fifth, which join the geniculate
ganglion, pass along the facial trunk, and leave the facial trunk as the chorda tympani
nerve. It was Hu^lings Jackson who first declared he had never seen undoubted
paralysis of the palate in association with lesions limited to the facial nerve, that the
palate is to a certain extent asymmetrical in most people, and that this fact had not
hitherto been sufficiently allowed for. It is. moreover, a clinical fact which Gowers
has insisted upon, that loss of taste is only associated with lesions of the facial nerve
situated at some point between the geniculate ganglion and the styloid foramen.
Lesions of the facial nerve behind the latter point do not give rise to loss of taste.
C3inically, it is of great importance to remember that the Fallopian aqueduct is
pierced by three structures, and through these holes inflammation may spread to the
fooial nerve. The first contains a small nerve twig from the facial nerve to the
stapedius muscle. The second contains an arterial twig from the tympanum for the
nutriment of the structures in the aqueduct. The third contains the chorda tympani
nerve which comes off from the facial \ inch above the stylo-mastoid foramen, and
passes forwards between the handle of the malleus and the stapes, turns downwards,
and after giving a vaso-constrictor branch to the submaxillary ganglion, terminates
in the tongue, which it supplies with taste fibres at the tip and along the anterior
two-thirds of the margin.

In the CuNiOAL Investigation of cases of facial paralysis, as in other
disorders of the nervous system, the first step is to discover the position
of the lesion and then its nature. This is done by investigatmg first, the
muscles that are affected ; secondly, the condition of the hearing ; thirdly,
the condition of the taste ; and fourthly, the electrical reactions.

The Symptoms of complete paralysis of the facial nerve (Bell's paralysis)
are (i.) an obvious one-sided alteration of the face which is pulled up away
from the paralysed side by the una£Eected muscles, the forehead and
cheek of the paralysed side being smooth and expressionless, (ii.) The
patient cannot shut his eyes, or in slight cases he cannot keep them shut
when we try forcibly to open them, (iii.) The comer of the mouth is
drawn up when he attempts to screw up the eyes, he cannot smile or show
his teeth. He cannot whistle, and the food collects between the cheek
and teeth, (iv.) The taste and (v.) the hearing may be affected in certain
cases (see below). Paresis of the palate used to be mentioned, but the
palate is now known to be supplied by the spinal accessory. In the course
of many months the affected side becomes drawn up by contraction of the
paralysed muscles (Fig. 168). Facial paralysis must not be confused with
hemiatrophy facialis (see below).

884

THE NERVOUS SYSTEM

IIW

The Varieftiei of Fadal Paralsrsif differ according to whether the lestoa is (a) in the
brain, (6) in the facial nucleus, or (c) the ^ial nerve, (a) is incomplete, bat (5) and
(c) are complete (or Bell's) paralysis. What follows should be oomjiared with Fig. 167.

Itf

Fig. 107. — ^The Facial Nbbyb, its course, and connections. — 1, stylo-mastold foramen ; 2, then
pyramidal decussation ; 8, decussation of facial fibres in the pons. G.T., chorda tympaai :
S., branch to the stapedius ; E.P., S.P., and O.P., external, superficial, and great peCzonI
nerves ; O., the otic, and M., MeckeVs ganglia ; P.A., posterior auricular branch ; a, aaditory
netve ; Pal., sensory branches from the palate to the second division of the fifth (oompae
Fig.iee).

(a) With Cbbbbral (Sufba-nuolbab) Lbsions facial paralysis is extremdy oomraoa.
and it differs considerably from that of lesions situated at or below the facial nnolem
(i.) It is nsnally associated with hemiplegia on the same, or oooasionaUy on the c^iposite.

S B17 ] SAOlAh NESFE 88S

side. If (aa i« naual) tho hemiplegia is on the same side u the facial palsy, the lesion
ia situated in the internal capsule ot aiMve ths pon«, but in orosaed hemipleg^ it is
situated fit the pons, (ii.) The upper halt of the faoe is exempt from the paralysis
(tbe paUent oau close his eyes), beoause, it ia auggested, a certain number of the fibres
of the fiteial nerve escape dsatructioa. Infra-nuclear lesions, on the other hand, dve
riao t« paialysis ot all tho facial muaolea — Bell'a paralywa, as it is called, (iii.) The
miueular power is speedilj restored ; and (It.) there are no electrical changes. The
an»tonuaal leaiona are thoae of hemiplegia (^.v.). H^Bterioal facial pali7 is extremely
race. It is slight, and the platysma is said to be exempt.

(b) NucLBAR Lesions are race, (i.) Atrophy and marked R. D. supervene ettcly.
(ii.) Diplopia may be present owing to the proximity and involvement ot tbe sixth
nucleus, (iil.) All tbe facial muscles are affected, but some more than others. If the
lips are mainly affected, we most suspect glosso-labio -laryngeal paraJyaia, and should
inveatigato movements of the tongue and lacynx. If the lips are exempt, and the

Fig. ISS.— FlCUL PuULTSta.— ThSa picture appears to represent rlrU fsdml paralyiii, bot Id
reality It rapraMota the lv» ot s nun aged lortr-two wltb paralysis ol the l»ft side, which
hod occmred two ^Bsn pisvlaiiity coiuMiuent on middle-ear dlseue. It eihlblte, therelors,
late coDtisctare ot the psialyted juiucIh ot tbe lelt aide.

upper part of the faoe alone is paralysed, we have pcoiiably to do with a nucloar
leoion affecting chiefly tbe upper part of the nuoleua, such as arises in rare casw of
diphtheria, a[wal affections, such aa tabes and disseminated solerosiB, race oases ot
focal lesioD, and anterior poliomyolitJa spreading upwarda.

(t) BeD'f Puilyiii. — InrRA-SDOLiAB Lssidiis give rise to paralysis ot aU the
Jaciid tnutda on one side (Bell's pacalyais), bat the symptoms will vary somewhat
with the precise locality of the lesion.

(1) Lesions of the /octal trunk just in front of the pons ace known by (i.) complete
pacalyais of all musoles ; |ii.) B. D. and wasting ; (iii.) possibly some nerve dei^ess
by involvement of the adjacent auditory nerve ; but jiv-) taste is always normaL
GumnatDQB and other tumours may affect tbe nerve here.

(2) Lesions in tbe Faiiopian aqutdtict (perhaps the commonest position) are known
by (i.) complete paralysis of all the muscles, coming on very suddenly ; (ii.) R, D. and
wasting in the coarse ot a week or two ; and (Ui.) taste of tip and side of the tongue
lost, owing to paralysis of the chorda tympani, this beirg the pathognomonic featnre

886 THE NERVOUS SYSTEM [ f §17

of neuritis or other lesions in the aqueduct, (iv.) There is no nerve dcslneas, bat the
hearing is generally affected. One of the commonest causes of facial paralysis is
disease of the middle ear, the inflammation spreading to the facial nerve in the aque-
duct, a condition of some gravity, because the bony waUs do not allow of the expansion
of the nerve, and the compression aggravates the condition. In some cases paralysis
of the stapedius muscte may, in the absence of otitis media, give rise to increased
acuteness of hearing, especially for low tones, on account of the unopposed action of
the tensor tympani.

(3) Neuritis External to the Skull (rheumatic or other) produces (i.) paresis of all
muscles, but usually incomplete ; (ii.) recovery usually ensues in a short time ; (iii.) there
may be some diminution of faradic reaction, but no R. D. ; and (iv.) no loss of taste
unless the inflammation spreads into the aqueduct.

Among the Causes of BdVs Paralysis otitis media or some other affection of the
middle ear is perhaps one of the commonest, as above mentioned, and a hiatory or
evidence of this is often obtainable. A simple sore throat may spread to the middle
ear and cause facial paralysis. Exposure to chill, as, for instance, in a railway carriagi\
is certainly a very frequent cause of facial paralysis, especially of Variety c (3). It
sets up a neuritis or peri-neuritis, which may spread up the nerve into the aqueduct,
as evidenced by an associated loss of taste in some cases. It occurs for the most
part in gouty or rheumatic people and those between twenty and thirty-five years of
age of either sex. In nearly three-fourths of nineteen cases of facial paralysis lately
under my care a history of chill or exposure could be revealed. The paralysis comes
on quite suddenly in the course of twenty-four to forty-eight hours after the exposure.
and is rarely quite complete. In the course of three days there may be some loss to
faradism, but in the course of four or five weeks the paralysis generally dears up.
Fracture of the base may result in facial paralysis, forceps applied during birth, or
boxing the ears in childhood, as in a case mentioned by Gowers. Basal meningitis,
especially of syphilitic origin, may involve the facial nerve, but usually some other
cranial nerve as well. Bare cases of hiemorrhage into the aqueduct have been con-
firmed by post-mortem. Inflammation and new growths of the parotid are generally
sufficiently obvious as causes of the condition. Diphtheria and alcohol are occa-
sional causes.

The Prognosis of facial paralysis as to recovery depends partly upon the positioa
and partly upon the cause of the lesion. The prognosis of supra-nuclear conditions
depends upon the concomitant symptoms. The prognosis is much more serious in
all lesions within the skull than those external, and especially when the lesion is within
the aqueduct, which invariably results in permanent degeneration of the nerve. In
oases of external neuritis due to chill lecoveiy is the rule. The electrical changes
give us valuable information as to prognosis. My general rule is as follows : If th^
arc no, or very slight, electrical changes in the second or third week, recovery is the
rule, but if the reaction to faradism lemains markedly lowered, and especially if it
is quite lost for three months, the chance of recovery is small ; if for six months, iiiir.

The Treatment in most cases is hopeful. It must be directed to the cause, Mid the
assistance of an aural surgeon is generally required. Even apart from syphilis, iodide
of potassium in small doses is very useful in rheumatic cases, especially if combined
with quinine. As a remedial measure galvanism is of great use to restore the nutritioo
of the muscles and the function of the nerve, if applied regularly.

Diplegia Facialis, or double facial paralysis, is somewhat difficult of detection, but
it is characterised by a total absence of expression, an inftbility to close both the
eyes, and an absence of adequate movement around the mouth in talking. It is a
much more serious condition than one-sided facial paralysis because of the Issions
which it accompanies.

Double facial paralysis may be caused by some of the lesions previously mentioned
occurring on both sides, su^h as (i.) basal lesions (e.g., syphilitic meningitis or tumours),
or (ii.) double otitis media. In both of these it generally happens that first one fsdal
nerve is affected, and then some weeks or months later the nerve of the other side.
(iii.) Diplitheria. and (iv.) focal lesions in the upper part of the pons may affect both
sides at once. Diphtheria is, I believe, a more frequent cause of slight double facial
paralysis than is generally recognised. It is evidenced by the expressionless aspect

§ «18 ] A UDITOR Y NERVE 887

of ohlldren suffering from diphtheritio paralysis, (t.) Fooal lesions in the upper part
of the pons in the position of the decussation of the facial fibres are extremely rare.

Hemiatrophy Facialis is a rare condition* consisting of atrophy of the skin and its
appendages, the subcutaneous tissue, and sometimes of the bones on one side of the
&oe, unattended by alterations in the sensation or muscles of the face. It must not
be confused with facial paralysis. It is believed to be due to a degenerative lesion
(possibly of the nature of poUomyelitis) of the upper part of the nucleus of the fifth
nerve, with atrophy of the upper part of the nerve trunk within the pons. One case
observed by the author^ followed a severe neuralgia which dated from an injury
to the vertex.

§618. The Auditory Nerve (the eighth) is the nerve of hearing and
orientation.

It arises by two roots. The dorsal or auditory root arises from the internal auditory
nucleus, and passes out behind the restiform body. The ventral root (orientation)
arises from the external auditory nucleus and passes out in front of the restiform body.
The two roots join and enter the internal auditory meatus to be distributed, the former
to the cochlea, the latter to the semicircular canals. The cortical centre for hearing
is in the first and second temporo-sphenoidal convolutions of the opposite side, that
for orientation is unknown. The auditory apparatus is shown in Fig. 169.

Clinioal IiTTESTiaATiON. — Hearing should be tested by the voice or a watch and
a tuning-fork. The presence of wax in the external meatus must be first excluded,
and if necessary the ear should be syringed with warm water after the wax has been
softened by warm oil or bicarbonate of soda solution (2 teaspoonfuls to the pint).
To test the acuteness of hearing, stand behind your patient, close one of his ears with
one of your hands, and place a watch in the other hand outside the range of his hearing,
then approximate it slowly, asking the patient to speak directly he hears the tick,
and then estimate the distance. Examine the other ear in the same way. Ascertain
on yourself what is the normal distance at which that particular watch should be heard,
and supposing this is 60 inches, and the patient hears with the left ear at a distance
of 5 inches, and with the right at 60 inches, then the acuteness of his hearing is repre-
sented by the fraction ^^g^. The hearing for the voice is indicated by the distance
at which the patient can hear whispered sounds, or by noting whether at 2 yards the
patient can hear whispered, ordinary, loud, or shouting conversation.

Weber^s Test. — ^To ascertain whether an impairment of hearing is due to nerve
deafness or to obstructive deafness, test the perosseus hearing by placing a watch or
a vibrating tuning-fork on the mastoid bone or on the centre of the patient's forehead.
If the deafness is due to disease of the auditory nerve it cannot, of course, be heard in
the affected ear, or, at any rate, not as well as in the good ear. This is known as
Weber's test negative, and indicates nerve disease. If the deafness is due to obstruct
tive ear disease (the nerve being intact) the sound will be heard quite as well, and
probably better, on the defective side than on the healthy side (Weber's test positive).

RinniPs Test, — ^In a normal person a tuning-fork placed on the mastoid bono until
no longer heard in that situation by the patient, can still be heard by him if moved
and held opposite the meatus (Rinn^'s test positive) ; it indicates an absence of middle-
ear disease. When the middle ear or conducting apparatus is definitely diseased
the tuning-fork cannot be heard opposite the meatus after it has ceased to be heard
when held on the mastoid (Rinn^'s negative).

Oalton's Whistle is for testing the upward limit of audition of a patient. Diminu-
tion of audition for high-pitched notes occurs in old age and in incipient nerve deaf-
ness. Paracusis WHlisii, " hearing better in a noise," is a characteristic of bilateral
middle-ear disease, and is usually associated with fixation of the stapes. Such patients
can hear conversation better in a train or omnibus. In boiler makers' and some other
forms of nerve deafness the converse is true.

Insfeotiok ov tub Ear. — Note should be made of any discharge and its character
(see below), any pain or tenderness over the mastoid (see below), any eczema of the

1 Trans. Clin. Soc. Lond., 1903.

8Sa THE NERVOVS 8T8TEM [ I «18

meatoB. etc. To ezkiniilo the mtatut (whioh should be done fi»t withont a ■peoalani)
tbe »nriole should be pnlled geatiy upwards and baokmids. the tr^us bong held
forwards bf » blunt probe. If a apeoolum is to be osed, the auricle should bo hdd
between the middle and ring fingers of your left hand (for the patient's right ear), the
■peoulum being inserted with jour right hand inwards and slighUj downwards aod
forwards. The speoolDin oao then be held between the thumb and forefingra' of TOnr
loft hand. It fneilitates examination to have a mirror on the forehead as in laiTiigoa-
oopj' (S 119) to reflect the light from the side of the patient's head. The convexity
of the floor of the meatus may be mistaken for an abaous or polypus. Cemmeu is

Fig. ISB.— AUDtTOBV ArpARlTDB (dlsgnmnutie rei>nMiilattoD) ot the lett side Men tron

tba bant, tha intetnil parts balna ma^lBed two-lold.

B.AJ(., Bxtenul sudKorr mestul, separated br tympsnia membrane riom tnapaaBm In wtiuii

B. b Utoated.
X.. OD h«ad et Hsilsni.

I., Inou flied to waO br Its short piooess, and artlenlaUng with tbe stapes bf Its Vmi pioe«w.
Bt-, Stapes, Hm loot ot which flta into tha leaostra OTtle.
T., Tanbole onulsting ot suMmle (below) and utrlcia (sboTa). Into tha lattm open tha tbiee

MmldrcDlar canals, saperior, postarlor, and eitanul {or braiiontal). Tba vastltnik leads an

to the seals vntlbali (ST.) ol the cochlea (C).
B., Jtamtn rotunda leadbig from the scale trmpanl (S.T.) to trmpanum.
E.T., Bnataahlan tube.

of dark colonr and soft ooneistence. The membrana tympani may preaent indrawing

(due to blooking of the Guataohian tube), oongeation, thickening, or loaa of IntltK,

atrophia areas, or perforations.
The Naso-Psaxykz should be nest examined. Note (1) tlie aetirity of the palatal

mnsolcfl. (Z) the Etutaohian tabes and baok of the nose by poBterior rhinoooopy, and

(3) the patency of each Dostril.
The Fatrvov or thb Eostaobur Tcbi is usually tested by inflation of (be middle

ear by Potiber's method, lllie noEile of (he rubber bottle is inserted into one nostril,
and both nostrils are then held oloeed between the thumb and finger of the operator.
The patient is then directed to swallow or to say " hie," and at the same moment the

§618a]

CAUSES OF DEAFNESS

889

air from the rubber bottle is forced into the nose. Deglutition raises the palate and
opens the Eustachian tube, and the air, having no other outlet, is forced into it. A
tube connecting the ear of the patient with that of the operator will enable the latter
to hear an audible *' pick " if the middle ear is inflated, and this will reveal the patency
of the Eustachian tube. A second point to note is the effect which inflation has upon
the symptoms — ^the hearing, tinnitus, or pain. The hearing is temporarily improved
in middle-ear or Eustachian disease, made worse in nerve deafness and unaltered in
otosclerosis. In Valsalva' a method of inflation the patient pinches his nostrils firmly»
and makes an expiration as if to blow his nose, but without allowing the air to issue.
The Eustachian aUheter is sometimes required to inflate for diagnosis or treatments.
It is not a difficult operation, but requires a little practice. Pass it tip downward
very gently along the floor of the nose to the edge of the hard palate, the patient
being directed to breathe through the nose so that the soft palate may droop. Im-
mediately the tip of the catheter has reached the edge of the hard palate turn it
upwards and outwards, and it will enter the Eustachian orifice. It may be aided by
the patient swallowing at the same time. The nozzle of Politzer*s bag may now be
carefully introduced, and inflation performed as before.

§ 618a. Causes of Deafness. — ^Two kinds of deafness are recognised by
aural surgeons ; nerve deafness due to lesions of the auditory nerve, and
obstractive deafness due to some disease in the middle ear or auditory
passages.

Diagnosis of Nerve Deafness and Obstruotivb Deafness.

Nervt Deafness,
Diminution of bone-conduction.

Loss of hearing for very high-pitched

tones.
Decreased hearing in midst of noise.
Hearing for conversation relatively better

than for watch,
l^nnitus occasional.

Obstructive Deafness.

Loss of air-conduction only, with nega-
tive Binnd.

Better hearing for very high than for
very low tones.

Increased hearing in midst of noise.

Hearing for conservation relatively worse
than for watch.

Tinnitus usual.

The OaasM ol Deafnew, slightly altered from Dr. Dundas Grant's arrangement,^
may be summarised as follows :

Verve deafneif . — a. Coming on aaADXTALLY, withoxtt bvidbkobs of intbagbanial
DiSBASB, may he due to~^

1. Toxic causes — e.g,, quinine, salicin, tobacco.

2. Chronic ansomia, or congestion of the labjrrinth.

3. Paresis from chronic concussion — machinery, guns, etc

4. Hysterical deafness.

h. Nerve Deafness coming on obadually, with nrvoLVBMBirr of other nbbvous

STBUOTUBBS.

1. With facial paralysis would indicate either disease of the petrous bone (when
thero would be discharge of some kind) or gumma, tumour, or pachymeningitis within
the skulL

2. With the sixth nerve or spinal accessory — basal pachymeningitis, or a tumour.

3. With hemiplegia of the same side — disease of the temporo-sphenoidal lobe or
motor strands below.

4. V^tii crossed hemiplegia — disease of the pons.

5. With hemianesthesia — disease of the hinder part of the interior capsule.

6. With failuro to understand spoken but not written words, without loss of speech
(word deafness) — disease of the left superior temporo-sphenoidal lobe.

7. With locomotor ataxy or disseminated 8clerosis---degeneration of the auditory
nucleus.

^ Medical Anmud, 1895.

890 THE NERVOUS SYSTEM [ § tlSa

c. Nerve Deafness of Sudden Onset.

1. Sudden onset of deafness, with an apoplectiform attack, followed by roomTent
vertigo, would indicate M^ni^re^s disease (§ 529a).

2. With sudden hemiansesthesia or hemiplegia — hsamorrhago into the tempoio-
sphenoidal lobe, internal capsule or pons.

3. If dating from a mental or emotional shook — ^neurotic or hysterical deafness.

4. If dating from forcible syringing, loud noises, explosions, or blows on the head
— concussion of the labyrinth. Fracture of the base may be attended by fraotore of
the capsule of the labyrinth.

d. Nerve Deafness of Moderately Acute Onset.

1. Without pyrexia, nerve deafness may come on within a few hours in syi^uHtio
disease of the labyrinth, and in leukaemia. Acute congestion and acute aniemia of
the labyrinth coming on with nausea and giddiness are also causes.

2. With pyrexia, primary inflammation of the labyrinth may supervene with oere-
bral symptoms during or after various specific fevers, mening^ inflammation of the
auditory nerve, or injury.

Obitniotive deafnesf, or deafness due to disease of the middle ear or auditory
passages rarely comes on (a) suddenly, excepting from impaction of cerumen. If it
comes on (h) acutely, it is probably due to acute catarrh of the Eustachian tube.

Chbonic Obstructive Deafness of some standing :

a. Without a History of Previous Discharge,

1. If the deafness dated from an acute naso-pharyngeal catarrh, tinnitus is not
constant, inflation with Politzcr's bag gives some relief, and on inspection, the tym-
panic membrane is indrawn, opaque, and thickened, the disease is the exudative form
of chronic catarrh of the middle cur.

2. If the deafness had an insidious onset, tinnitus is a prominent symptom, inflation
gives no relief, and on inspection the tympanic membrane is somewhat opaque, bat
practically normal, the disease is otosclerosis.

6. With a History of Previous Purulent Discharge, — ^The deafness is probaUy due to
perforation or cicatrices resulting from suppurative inflammation of the middle ear.
and inspection of the drum confinns this.

Combined ObstmotiTe and Verre Deafneif. — In this condition it is sometimflB a
little difiicult to make out the exact state of matters. However, such cases may be
grouped into those with and those without discharge.

a. If there is a history or presence of discharge, the commonest condition which gives
rise to it is a suppurative otitis media spreading to the labyrinth. In these circiun-
stances we get signs of nerve deafness gradually supervening on those of obstractive
deafness.

6. If there be no discharge, past or present, the most usual conditions are: 1. Disease
of the cochlea or ankylosis of the stapes supervening on an old chronic catarrh of the
middle ear. 2. If the history of nerve deafness precedes the obstructive deafness
the middle-ear catarrh has supervened on the nerve deafness.

Pain in the Ear may be due to : 1. Otalgia, when there is no sign of local disease or
defective hearing, and a reflex cause such as a bad tooth is present-. 2. Disease of the
external meatus, such as furuncle or eczema. 3. Disease of the middle ear, when these
is deafness, some pyrexia, and examination reveals congestion of the memlwane.

Pain in the Mastoid Region may be due to : 1. Mastoid neuralgia, which some-
times follows old mastoid disease. 2. Accompanied by redness, swelhng, and tokder-
ness — ^inflammation of the mastoid lymphatic gland, periostitis, or abscess. 3. Aocoai-
panied by deep throbbing, pain and constitutional disturbance, it may be doe to
internal mastoiditis, which is often consequent on chronic suppuration.

Pain more or less oeneralisbd over the head, accompanied by pyrexia, may be
associated with the following diseases of the ear-.

a. Acute Diseases. — 1. Acute middle-ear suppuration, which is relieved by ootlei
of pus ; 2. mastoiditis ; 3. acute meningitis ; 4. pyrexia.

6. If associated with a history of chronio suppuration from the ear: — I. If the
temperature is continuously high, it may be due to retention of pus, extradnnl
abscess, or meningitis. 2. If the temperature oscillate, th^re may be pyssmia, or siniis
thrombosis. 3. If the temperature after an initial rise is normal or subnoimal, and

§ 619 ] OA U8Ea OF DEAFNESS 891

tliere are headache, slow pulse, and delayed cerebration, suspect abscess of the tem-
poro-sphenoidal lobe.

Discharge from the Ear. — ^A sticky oozinq discharge may be due to eczema of the
meatus or condylomata. A HiEMORBHAQio discharge may be due to vascular granula*
tions or erosion of bloodvessels occurring with middle-ear disease, or (rarely) vicarious
menstruation in hysteria. An offensive SAiaous discharge, with fungating granula*
tions, acute radiating neuralgia, and enlargement of the neighbouring glands, is
characteristic of malignant disease of the ear.

A PT7BTJLENT discharge (a) which is or h(U been copious, and associated with deafness
from the beginning of the symptoms, is due to acute or chronic suppuration of the
middle ear. When associated with chronic suppuration, it may be due to the presence
of polypus, granulations, or cholesteatoma, caries of the malleus, incus, or temporal
bone, disease of the mastoid antrum or naso-pharynx, or to constitutional causes, such
as diabetes mellitus, tubercle, ansemia, or syphilis.

{b) A FTTRULBNT discharge which is not, and never has been, copious, and deafness,
which if present, did not supervene till an interval after the onset of symptoms, may
be duo to external disease of the ear, acute or chronic.

Tinnituf, or noises in the head, comprise, as Dr. Dundas Grant aptly remarks,
** as many varieties of sensation as the patients' powers of description can make
them.'* Tinnitus may be duo to impacted wax or disease of the ear, when there is
usually associated impairment of hearing and local signs. A humming tinnitus, worse
on lying down and taking food and stimulant, is due to venous congestion ; relieved by
lying down and taking food is duo to ansemia. Tinnitus taking the form of voices or
music is auditory illusion, due to mental disturbance, and often originates in chronic
disease of the organ of hearing. A pulsating tinnitus (1) checked by compression of
the carotid artery is due to arterial congestion of the middle or external ear ; (2) checked
by compression of the vertebral arteries in the sub-occipital triangle — arterial con-
gestion of the internal ear ; (3) audible on auscultating head or ear — ^probably intra-
cranial aneurysm.

Vertigo and its causes have been dealt with in § 511. M^ni^re's disease is described
in § 529a. Pseudo-M6ni^re's disease may occur with middle-ear catarrh.

Orientatioii« or, as it is sometimes called, equilibration, is the function of that
branch of the eighth nerve which goes to the semicircular canals (compare § 503).
Disease of this branch or of the semicircular canals gives rise to sensations of giddiness,
the type of which depends upon the particular part involved. Spontaneous nystagmus
may be present. The condition of the vestibular system can be ascertained by
endeavouring to produce nystagmus, by syringing with cold and hot water, or by
rotating in a rotating chair. Normally, S3rringing with cold water (24° C.) induces
a nystagmus to the opposite side ; while hot water (42** C.) produces an opposite effect.
Kotation (ten times in twenty seconds) produces a nystagmus towards the side from
which the patient is rotated.

The Prognosis and Treatment of these various symptoms depend mainly on the
cause in operation. To deal with them individually would be beyond the scope of
this work. Nerve deafness is not very hopeful. Any toxic or other cause in opera-
tion should, if possible, be removed, and weak galvanism may be tried. Obstructive
deafness is, in a large proportion of cases, due to middle-ear catarrh, which is more
hopeful than nerve deafness. A certain amount of good may be done in chronic
catarrh by regular inflations, which the patient can be taught to do himself, and
regular izihalation of various remedies such as ammonium chloride. Acute middlcp
car disease requires prompt measures. Hot fomentations, leeches and incision of
the tympanic membrane may be necessary. Warm drops of glycerine with carbolic
acid should be used, and gentle inflation by the Eustachian catheter. Mastoiditis
and other intracranial symptoms demand surgical interference.

§ 619. The Glossopharyngeal Verve (the ninth) is the sensory and motor nerve of
the pharjmx. It supplies the middle constrictor muscle of the pharynx (and the stylo-
pharyngeus), and common sensation to the pharynx and the back of the tongue. In
the terminal part of its course it contains the taste fibres from the posterior third of
the tongue, which ultimately go to join the fifth (§615).

892 THE NERVOUS SYSTEM [H

Anatomy. — ^The nintii, tenth, and eleventh nervee arise from a longitudinal ooUe(V
tion of cells in the medulla and floor of the fourth ventricle situated beneath or ven-
trally to the calamus soriptorius. The ninth arises from the upper end, the tenth from
the middle and outer part, the eleventh from the lower end. The ninth is joined
by ascending branches from the lateral column as low down as the fourth cervical seg-
ment, and the spinal pskrt of the eleventh by branches as low as the sixth cervical seg-
ment. The spinal accessory is the only one which supplies voluntary muscles, and
it should be remembered that it is the accessory portion of this nerve which supplies
the larynx and palate through the vagus.

Paralysis of the Glossopharyngeal Nerve is practically never met with alone, and the
exact limitation of its functions has never been defined. Paralysis would be indicated
by (1 ) loss of sensation — i.e., insensibility to tickling — of the upper part of the pharynx,
and {2) some disturbance of deglutition. (3) The sense of taste in the posterior part of
the tongue should be tested in suspected cases.

§ 620. The Vagus, or Pnenmogastric Verve (the tenth) has widespread connections
with the respiratory passages, heart, oesophagus, and (through the sympathetic)
with all the abdominal viscera. It is also the motor nerve to the larynx, pharynx,
and palate (by fibres derived from the accessory portion of the spinal accessory, the
eleventh). The involvement of the vagus proper or its nucleus (fortunately not very
common) is evidenced by disturbeuices of the cardiac rhythm, slowing of the respira-
tion, and perhaps by vomiting, hiccough, sighing, and yawning. The motor effects
aro evidenced in the palate, larynx, and pharynx.

Labyngeal paralysis has already been referred to in § 127. The crioo-thyroid is
supplied by the superior laryngeal, and all the other muscles by the inferior laryn^cAl
branch of the vagus, both of which aro really derived from the accessory portion of the
spinal accessory nerve. Unilateral paralysis of the larynx need not produce any
symptoms, and is nearly always due to some local lesion of a laryngeal branch of the
vagus. Lesions above the level of the nuclei — ».e., when situated in the cortex of
both hemispheres, or in the descending motor tracts of both sides, always produce
bilateral paralysis (as in the case of the eyes), and this bilateral paralysis may be
complete, or affect only the abductors (a dangerous condition, which impedes in-
spiration). A lesion in the cortex or motor tract of one side is unattended by laryngeal
paralysis, since the opposite cortex can innervate both cords (Horsley and Semen).

§ 621. The Spinal Accesf ory Verve (the eleventh) at its origin consists of two portions.
(a) The accessory portion rising from the medulla joins the vagus, and gives to it
its motor functions for the larynx, palate, and pharynx (vide % 620). (&) The spinal
portion arises from the anterior horns of the first four segments of the cervioal cord,
and supplies the stemo -mastoid and trapezius (which aro also supj^ied by twigs
from the cervical plexus). When the stemo-mastoid is paralysed, the patient is
unable to turn his head to the opposite side. When the trapezius is paralysed, he is
unable to shrug his shoulders. This portion of the nerve is often involved in obscure
irritation producing torticollis.

The Soft Palatb is now believed to be supplied from the aocessory portion of the
eleventh through the vagus and the pharyngeal plexus (Ilg. 166). Pualysis of the
palate is evidenced by (i.) insufficient elevation of one (or both) sides of the palate
during phonation when the patient says " ah." Deviation of the uvula to one side
is not a proof of paralysis, (ii.) Inability to pronounoe words containing '* g '* and
*' b." (iiL) Regurgitation of fluids through the nose in advanced cases. As regards
the Causes of paralysis of the palate (1) it is more often met with in diphth^tie
peripheral neuritis than in lesions of the vagus or spinal accessory. (2) A lesson of the
nucleus of the accessory portion of the spinal accessory nerve is met with in bulbar
paralysis, and occasionally in amyotrophic lateral sclerosis and progressive muscular
atrophy. It is also met with occasionally In other spinal lesions, such ae tabe&
(3) Lesions of the motor tract above the nucleus, a condition that may occnr in hemi-
plegia due to a cerebral lesion.

§ 682. The Hypogloual Verve (the twelfth) is purely a motor nerve to the tongue.
Probably the orbicularis oris is also innervated from tiie nucleus of this nerve through

!«»] BULBAR PARALYSIS 893

the facial. One side may be paralysed in both supra- and infra-nuolear lesions, and
is evidenced by the deviation of the tongue towards the paralysed side when it is
protruded, o^^iring to the unbalanced action of the tongue muscles on the healthy side.
When the lesion is bilateral, the tongue is motionless. (1) Cortical and sub-cortical
lesions are very often attended by unilateral non-atrophic paralysis and by hemiplegia.
Articulation is only temporarily affected. Lesions producing this condition are men*
tioned under Hemiplegia. (2) Nuclear lesions give rise to atrophic paralysis of one
or (more commonly) both sides of the tongue, and the mucous membrane is thrown
into folds. In bilateral paralysis, speech, mastication, and deglutition are much
impeded. It is generally part of bulbar paralysis (infra). Both nuclei are generally
affected together by a degenerative lesion ; sometimes one is affected in tabes. (3) In
unilateral paralysis of the hypoglossal the lesion is usuaUy situated in the nerve trunk.
Sometimes there is a triad of symptoms, as first described by Dr. Hughlings Jackson —
unilateral hemiatrophy of the tongue, with paralysis of the palate and the larynx
on the same side. Such cases are mostly due to a localised pachymeningitis of syphi-
litic origin involving the trunks of both the hypoglossal and the accessory portion of
the eleventh. A fourth symptom is sometimes adde^ — ^paralysis of the stemo-
mastoid and trapezius from involvement of the spinal portion of the eleventh. Uni-
lateral lesions of the hypoglossal nerve trunk alone are also met with in parotid and
oth^r tumours of the neck, and occasionally neuritis.

S 028. Bulbar Paralysis (or glosso-Iabio-laryngeal palsy) is a bilateral, progressive,
atrophic paralysis of the lingual, labial, laryngeal, and palatal muscles due to slow
degenerative changes affecting the nuclei of the twelfth and the accessory portion of
the eleventh nerves. Its description comes suitably at the end of the cranial nerves
where several paralyses clinically and anatomically associated have been referred to.
The first Symptom usually noticed is alteration of the speech, which becomes thick
and indistinct, words being run into one another as though the tongue were too large
for the mouth. In reality, however, the tongue becomes wasted, and, as in other
atrophic paralyses, is the seat of fibrillary tremors. At first the lingual letters only
are difficult, but by-and-by, as the soft palate becomes paralysed, words containing
gutturals such as " ground " and ** grub " are impossible to the patient. Gradually
as the tongue wastes, the mucous membrane is thrown into folds, and the patient is
unable to protrude the organ. (2) The orbicularis oris is simultaneously involved*
The patient cannot whistle, and by the falling of the angles of the mouth the expres-
sion becomes mournful. The other muscles of the face are unaffected, but he cannot
inflate the cheeks, owing to the paralysis of the soft palate. (3) The vocal cords are
also paralysed, and phonation, difficult at first, becomes by-and-by impossible beyond
a meaningless grunt. (4) Owing to the affection of the soft palate and pharynx,
swallowing becomes difficult, and fluids regurgitate through the nose, and the saliva,
whioh the patient cannot swallow, dribbles out of the mouth over the edges of the
protruding lower lip. Occasionally the disease is associated with descending sclerosis.
The Diagnosis in typical oases is not difficult. Certain combined lesions, such as
that referred to under the Hypoglossal Nerve, may present a difficulty, but bulbar
paralysis is always bilateral. Myasthenia gravis (§ 574) resembles it, but presents
certain generalised symptoms. Psettdo-hidbar paralysis is due to bilateral disease of
the cerebral cortex in the lower part of the ascending frontal convolutions or about
the angle of the internal capsules, but this is much slower and often improves, and is
not associated with atrophy of the paralysed muscles.

The Prognosis is extremely bad. The progress is slow, but sure, and a fatal issue
invariably results, usually after a course of about one or two years, from complica-
tions or the extension of the disease to the vagus or other cranial nuclei.

The Etiology is obscure. The disease is practically confined to persons at or beyond
middle life. It may occur in association with, or independently of, progressive
muscular atrophy, and the morbid anatomy is probably identical with it. The
occasional occurrence of an acute form of bulbar paralysis (due to acute softening
analogous to acute anterior poliomyelitis) makes their identity more complete.

Treatment is unavailing, though antis3rphilitio remedies may be tried in oases
having a history of syphilis.

804 THE NERVOUS STSTEM IK9U.

THE SKULL AND SYMPTOMS REFERABLE TO IT.

§6S4. The Skull, as the brain-case, is related to neurology. Scazs,
• exostoses, and the traces of syphilis may be found. The cranial deformities
of hereditary syphilis and of rickets are given in the table in § 447 and
in §13.

The circumference of the skull is greatest at the level of the external occipital pro-
tuberance and glabella.

Average in male adult 66 cms.

female adult - Moms.

children aged 12 years 50 cms.

„ ,, „ ,, 12 months .... 45om8.

,, „ infants new bom 35 to 40 oms.

The average measurement of the naso-occipital arc in the male adult is 35 cms.

The microcephalic and macrocephalio skulls, facial asymmeUy, narrow forehead,
soapho-cephalic skull (with high vertex and narrow transverse diameter), protmding
teeth, or a high narrow arch of the hard palate are all regarded as degenerate or
neuropathic evidences, but they are not infallible signs.

External Landmarks of the Brain. — ^The chief cerebral structures to locate are the
fissure of Rolando and the fissure of Sylvius. The fissure of Rolando is a most im-
portant landmark, and may be found by drawing a line from the root of the nose to
the occipital protuberance. Then mark a point } to } inch behind the middle of this
line, and draw a second line from that point downwiuds and forwards at an an^ of
67 degrees ; the second line will lie over the fissure. This is conveniently done in
practice with soft metal joined at the required angle. The fissure of Sylvius is found
by drawing a line from the external angular process of the frontal bone to the occipital
protuberance. The fissure starts at a point 1| inch behind the external angular
process. The horizontal ramus of the fissure lies beneath a line drawn from this
point to the parietal eminence.

Sir William Macewen attaches importance to the percussion of the skull as an aid
to the diagnosis of intracranial tumours. X-rays sometimes assist.

S 625. Hydrocephalus is a distension ol the ventricles of the brain with fluid. It
occurs in two forms : (a) Congenital or infantile ; and (6) acquired or secondary hydro-
cephalus.

(a) Typical oases of Conqbnital HYDSOOBPHiiLns may be recognised by the shape
of the head, which is enlarged and dome-shaped, projecting all round and beyond the
bones of the face. The fontanelles are very wide, and Wormian bones may fill up
the gaps between the cranial bones. The ^oe in proportion to the size of the head
seems to be extremely small. The orbital platea of the frontal bones are pushed
downwards, so that there is exophthalmos, and the eyelids do not cover the B(derotio&
The condition dates from birth. It may exist before birth sufficiently to obstruct
labour, or it may be so slight as not to be noticed until the child is one or two years
old. The circumference of the head of a child of four may reach as much as 25 or
30 inches. The general symptoms consist of bodily weakness and developmental
delay, and backward mental condition, which shows itself in the slighter oases as
a constant peevishness, and in the graver cases as idiocy. In some cases the intelleot
is quite normal. Spina bifida, talipes, encephalocele, and other developmental
deformities may accompany hydrocephalus. The Causes of this form of hydro-
oephalus are not known.

In slight cases the Diagnosis may have to be made from rickets, in which there are
(1) a bossed and square shape of the head, (2) a flattened instead of a dome-shaped
vertex, (3) evidences of rickets in the other bones of the body.

Prognosis, — ^Most cases of congenital hydrocephalus die within the flrst five y^a^a
of life. Moderate cases sometimes live until the twelfth year. Mild cases of hydro-
cephalus sometimes do not deteriorate further. The patient lives without other
symptoms perhaps for the normal span of life.

§ 625 ] H YDROCEPHALUS 896

(&) The symptoms of Acquirbd Hydroobphalus are leas decided. They come on
insidiously at any age, and are associated with those of the causal condition. The
head does not ei^rge if the disease supervenes after closure of the fontanelles, but
there are symptoms of cerebral compression (§§ 547 and 551), and sometimes gradual
blindness, due to optic neuritis.

Causes. — ^Acquired or secondary hydrocephalus mostly depends on some obstmc«
tion of the veins of Galon, such as that produced by a tumour at the base of the brain^
or in the third ventricle, or the iter. It may also result from intracranial inflamma*
tion, especially post-basic meningitis (§ 549). Pressure on the middle cerebral or
straight sinus, into which the vense Galeni empty, has the same effect (§ 551).

The TretUmeni of congenital hydrocephalus is not hopeful. Drugs are powerless
to promote the absorption of the fluid. In the milder oases the treatment resolves
itsdf broadly into a general strengthening or tonic treatment. In other cases lumbar
puncture, similar to that successfully used in tuberculous meningitis, has been
employed with a measure of sucoess in hydrocephalus. A smooth, fine aspirating
needle is introduced between the third and fourth lumbar vertebrae, a little to one
side of the middle line, to the depth of 2*5 centimetres in children and 5 centimetres
in adults. One to one and a half ounces have been removed at a time (Quincke).
It is especially worthy of trial if pressure symptoms are present. The treatment of
acquired hydrocephalus is not much more promising, unless the cause is removable.

CHAPTEK XX

'-i '

EXAMINATION OF PATHOLOGICAL FLUIDS AND CLINICAL

BACTERIOLOGY

In this chapter the methods of obtaining various pathological flnids, how
to examine them, and their characters, will be briefly described, and in
conclusion, an epitome of the chief bacteriological data required for
clinical work will be given.

§ 626. Methods of Obtaining and Enmination of Pathologioal Flnidi.— Flnida are
obtained by puncture with an ordinary hypodermic needle or with ezfdoring needles*
which are made specially strong, and with somewhat larger calibre to permit of
turbid fluid entering them. The needle must be boiled before use, and the skin thor-
oughly cleansed with soap and water, ether, and 1 in 30 carbolic acid. Cooaine or
eucaine may be painted over the spot or injected in the vicinity, or the part nmy be
frozen with the ethyl chloride spray.

The pleural cavity is best explored at the ninth space just behind the posterior
axillary line, or at the site where localised dulness is present. Paracenteeis thoracis
is described in § 85.

P^caidial fluid is obtained by inserting the needle ^ to 1 inch to the left of the
sternal margin in the fourth or fiftii interspace. Unless we are certain that the peri-
cardium is very full of fluid, it should never be attempted. Paraoenteais perieaidii
has been described in § 38.

The peritoneal cavity may be explored for fluid in the middle line, to avoid Mood-
vessels, or at the side, above the anterior superior iliac spine. The puncture must be
made over a dull area. Paraoenteeis abdominif for the removal of ascitic fluid is
performed with an ordinary trocar and cannula. A many-tailed bandage is fini
placed under the i>atient, and the tails are tightened up one by one to maintain the
ab<lominal pressure as the fluid drains away. Without this precaution the patient may
suffer collapse from the rapid dilatation and congestion of the splanchnic area. Some
advise a small prelimmary incision through the skin, or the trocar may be thmst
through the skin in the middle line. The fluid drains away through a long rubba*
tube into a pail by the side of the bed on the floor. The end of the tube should dip
under an antiseptic. Before puncturing in the middle line care must be takco to
ensure the bladder being empty. Southey's tubes may be employed instead of the
trocar and cannula. They act as efficaciously though more slowly.

liver Pnnotuie is performed in order to discover the presence of pas or of the
Leishman-Donovan body in Kala-azar. When a hydatid ojrst is present, Kver
puncture is not advisable on account of the danger of general infection. It is a
necessary precaution that the needle should not be more than 3^ inches long ; with a
needle of this length it is not possible to injure the portal vein. The needle should
be first introduced in the mid-axillary Une ; afterwards it may be introduced wherever
necessary. The needle and syringe must be absolutely dry. The patient should
hold the breath during the puncture, and a tight bandage is applied immediately
after. If a bacteriological examination is desired, it is well to have a tube of eultme
medium ready, and to eject the material straight into it. reserving some for making

896

§686] LUMBAR PUNCTURE 897

smears. II the Leishman-Donovan body is to be sought for, the contents of the end
of the needle are to be spread on a slide and films made from the blood in the syringe.

Spleen Pnnotnre is not performed so much nowadays as formerly, owing to the
ooourrence of accidents when the spleen has been very congested.

Gland Ponotore is employed to detect plague bacilli and trypanosomes. The
technique is similar to that of puncture in any other region.

Lnng Pnnotore has been tried. It is not to be advised, as there b some danger of
spreading infection and the results are not of very great value.

Lumbar Pnnotnre is employed chiefly for diagnosis of the character of the fluid in
increased exudation into the sub-dural space. Children should be anaesthetised.
For adults local anasthesia alone is sufficient. Employ an antitoxin needle, pre-
ferably one of platinum and iridium, the most convenient length of which is about
3 inches in an adult, and 2 inches in a child. The patient, if an adult, should sit up,
leaning well forward, with the head low. Draw a line across the patient's back at the
level of the highest margin of the iliac crests. This line intersects the vertebral
column at the tip of the fourth lumbar spine. Having carefully sterilised the skin
at about this spot, it is rendered ansesthetic by an ethyl chloride spray. The operator
places his left index finger on the fourth lumbar spine as a guide, and then, with
the right hand, pushes in the needle about } inch below and } inch to the right of
this spot. It should be inolinad inward and slightly upward. In the case of children,
the best position is with the child on its left side, the back being bowed as much as
possible. If the needle strikes bone, it should be withdrawn until the point is just
beneath the skin and inserted in a slightly different direction. The syringe should not
be removed until the spinal cord is reached ; after a little practice this will be easily
recognised by the sudden lessening of resistance. Then remove the syringe and collect
in a test-tube the fluid which falls out. As little fluid as possible should be removed
when the puncture is made solely for diagnostic purposes. If the first portion is
blood-stained, it is necessary to reject it, and for this reason it is wise to have two
test-tubes ready. The fluid normally runs out drop by drop, but when under in-
creased pressure, as in hydrocephalus and meningitis, it will sometimes spurt out ;
the intrathecal pressure may be roughly gauged by the rate of flow. For examination
(p. 898) 5 c.c. are enough, but for treatment (below) 10 or 15 c.c. may be removed.
After the puncture has been performed the patient should remain lying down, and if
he is confined to bed it is well to raise the end of the bed and remove all pillows.
These are useful precautions which may be disregarded without ill results in many
cases. If the sitting position is employed for the operation, the patient should lie
down for half an hour afterwards.

Therapentio Hies of Lnmbar Pnnotnre. — Recently this method has attracted atten-
tion, not only for purposes of diagnosis (p. 900), but for treatment. The withdrawal
of 5 to 15 c.c. of cerebro-spinal fluid relieves not only intrathecal but intracranial
pressure ; probably it acts in other ways also— e.^., by " flushing " the theoa verte-
bralis. The fluid spurts out when the pressure is too high, and in some cases it may
be allowed to run till it comes in drops.

1. Li tubercidou8 meningitis it relieves the symptoms of cerebral compression, and
cases of recovery have been recorded after repeated tapping. Possibly it acts in the
same way as tapping in cases of tuberculous peritonitis.

2. In epidemic cerebro-spinal meningitis 10 c.c. may be removed, and 30 c.c. of
Mexner's serum introduced.

3. In many cases of Coma and Oerebral compression, from whatever cause arising,
it is a useful palliative measure.

4. Inaccessible cerebral tumours so treated result in the temporary relief of the
symptoms of cerebral compression ; not more than 5 or 6 c.c. should be withdrawn
at a time, for fear of hssmorrhage into the tumour substance.

5. In fracture of the base of the shuU cases of recovery have been reported.

6. Oases of urcsmic coma or convulsions have been promptly relieved, and have
ultimately recovered (McVail, British Medical Journal, 1903).

7. In cases of tetanus the antitoxin may be more advantageously introduced by
lumbar puncture than hypodermically, and may be given with stovaine and morphine.

8. Oases of strychnine poisoning have been treated by eucaine introduced in this way.

898 PATHOLOGICAL FLUIDS AND CLINICAL BACTERIOLOGY [|

9. AnsBsthesia of the lower limbs and trunk — &pinal ancssthesia — is produoed by
the introduotion of oooaine. stovaine, and novocaine by lumbar puncture after with-
drawing a larger amount of fluid than that introduced.

How TO Examine Patholooical Fluids. — Fluid which has been withdrawn
from the pleural, pericardial, or peritoneal cavity, or from a cyst, should be placed
in a conical vessel, and allowed to settle, and its physical and chemical charaoten
noted. The Colour should be observed, whether clear, turbid, or red, aa with blood,
or opaqu3 from abundant cellular constituents, or excess of fat. as in chylous exuda-
tions. The Beaction is usually alkaline. The Odour tells little as a mle« except in
the case of cysts which have been in the vicinity of the intestinal canal. The Com-
sistenee is usually watery ; if viscid, mucin is present, as in a distended gall-bladder
or an ovarian cyst. Clotting after standing indicates the presence of fibrin, ^le
Specific gravity must be noted. The Deposit must be examined under the microscope.
Blood-cells, white and red, may be found, the former being more readily seen by the
addition of acetic acid, which brings out the nuclei. Cancer cells may be found in
malignant disease of the wall of the cavity, and are distinguished from epitlielial
cells by being large, and occurring in groups. The discovery of booklets (Fig. 74.
§ 254), or pieces of lining membrane of hydatid cysts, crystals of cholesterin. leoein
or tyrosin, or various germs, or the amosba of dysentery, or.actinomyoes, may clear
up a difficult diagnosis. Fatty acid crystals in groups favour the diagnosis of caaoer.
The Chemical Examination is then proceeded with, after filtering the fluid. Albamcnd,
nuoleo-albumen, and mucin are tested for as in urinary examination. For quantita-
tive examination of albumen the fluid is first diluted to a specific gravity of 1008,
and acidified with acetic acid, then measured in Esbach*s tube (§ 276). To deteet
urea, first remove any albumen by heating and filtering ; then evaporate the fluid
to small bulk, and test as in urine. To detect sugar, render the fluid slightly acid.
boil, filter, evaporate to small bulk, and test as in urine.

When the fluid is suspected to come from a pancreatic cyst, it is tested to ascertain
if it can digest albumen in an alkaline medium. The suspected fluid is added to milk.
After the casein is precipated, the Biuret test is tried. (A few drops of dilute solation
of copper sulphate, and excess of caustic potash, causes a rose-red hue in the presence
of peptones.) If present, it proves that the fluid has a peptonising power, and nothing
except pancreatic fluid can peptonise in an alkaline medium. In 03rst8 of some
standing, the power of peptonising may be lost owing to the destruction of the trypsin.

Characters of the Pathological Fluids (table, p. 899). In tlie pleural,
pericardial, and peritoneal cavities, inflammatory effusions (exudates) are
difliGuIt to distinguish from dropsical effusions (transudates). Cardiac
dropsy is more albuminous than renal dropsy. A fluid containing more
than 4 per cent, of albumen is probably of inflammatory origin ; a fluid
with less than 2| per cent, of albumen is probably dropsical. Blood in
distinct amount in these cavities is highly suggestive of cancer, but has
sometimes been foimd with tuberculous disease of the pleura and with
peritonitis associated with cirrhosis of the liver. In such a case, examina-
tion of the deposit, revealing cancer cells or tubercle bacilli, would settle
the diagnosis. A few blood-cells, sufficient to give the fluid a rosy tinge,
may occur with simple acute inflammation. The character of the cells
in a pleuritic fluid may aid the diagnosis of the cause of the effusion (cvto-
diagnosis) ; thus, an excess of lymphocytes points to tuberculous pleurisy ;
the predominance of polynuclear cells points to septic or other causes.
The special characters of the various fluids and cysts are given in tabular
form ; but a few words should here be said about the cerebro-spinal fluid.

Oerebro-Spinal Fluid should be clear, colourless, containing a trace of albumcii
and albumose. Fehling^s solution is reduced (7 by pyrocatechin). When the ftuid
which runs out is turbid, it indicates meningitis of some kind, and cover-glass films

■ liiKI
I IPtll

I I"

I i

ill

jUMi

i i 11 i
ipii I

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ill.
I

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ii|i jM!

■ ■ ■ f ■

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■ " 111

900 PATHOLOGICAL FLUIDS AND CLINICAL BACTERIOLOGY [§««7

should be made to study the organisms present. For microscopic ezaminataon it is
convenient to centrifuge and collect the deposit (see below). There may be found the
pneumocoocus or the diplococcus intracellularis of cerebro-spinal meningitis or other
organisms. The trjrpanosome has been found in sleeping sickness. In negative eases,
where tubercle is suspected, a g^nea-pig may be inoculated with the fluid. Other
organisms which may excite meningitis are : (1) Pneumoooccus, which is frequent
both in primary and secondary meningitis. (2) Streptococcus and staphylococcus
are almost confined to secondary forms of meningitis ; (3) B. influents ; (4) B. ooli.
B. typhosus, B. pestis, B. mallei. (5) Gonococcus and other micro-organisms are
very rare. (6) Malaria parasite and trypanosoma. The characters of the cerebro-
spinal fluid in the chief forms of meringitis are shown in the following table :

Form of Menin-
gUis.

Appearance of
Fluid.

CdU,

FUme.

CtiUwrt,

Tvbereulotu.

Clear.

Lympbocytefi.

Tubercle bacilli.

Sterile.

Cerebro-spinal
Fever,

Turbid, if early.
Clear, if late.

Turbid.

Polymorphs, if

early.
Mixed, if late.

Diplococcus of
Weichselbanm.

Pneumococci.

Diplococcus of
Welchtelbaom.

PneumococetU.

Polymorphs.

Pnenmoooed.

Staphyloeoeeal \

and StrepUh ^

eoeeal. )

Turbid.

Polymorphs.

Staphylococci
and strepto-
cocci.

and strepto-
cocci.

SvphUUic.

Clear.

Lymphocytes.

Nil.

Sterile.

For Cyto-Diaonosis, or diagnosis by the cellular elements in the cerobro-apinal
fluid, 5 CO. should be centrifuged for five minutes. After the supernatant fluid has
been poured away, take a scraping of the tube turned upside down, spread on a slide,
fix by heat, stain with licishman's stain, and mount. One slide may be stained with
Leishman's stain in order to ascertain the character of the cells. AnoUier slide
may be stained with Gram and eosin in order to differentiate the bacteria and show
whether they are intracellular or extracellular. Normal cerebro-spinal fluid by this
method will not show more than two or three lymphocytes in a microsooino field of
a magnification of 400 diameters (say 1 or 2 per cubic millimetre), sometimes none,
and no polymorphs. Purves Stewart recommends for accurate counting Foehs-
Rosenthars counting chamber, a modification of the Thoma-Zeiss instrument.
10 c.mm. of cerebro-spinal fluid are mixed with a special pipette with 1 o.mm. staining
fluid containing methyl violet and acetic acid. A drop is placed on the ooonling
stage, and the cells are counted. (1) In acute infective meningitis (brain or oord)
excess of both polymorphs and lymphocytes is foimd. In cerebral abscess without
involvement of the meninges there is no excess. (2) In tabes dorsalis and G. P. I.
there is so large an excess of lymphocytes (20 or 100 per field as compared with 2 oir 3)
as to constitute a diagnostic feature. Thus may functional diseasos of the nervous
system be excluded.

§ 627. Bacteriological Examination. — The subjects of somm - therapy

and immunity have been dealt with in §§ 386 to 388. Here wiU be

described in brief outline the methods of detecting and the appearance of

the various microbes commonly met with in clinical work. For laboratory

work the student must consult a special treatise.

The necessary apparatus consists of (1) slides and cover-glasses thoroughly cleansed.
(2) A pair of Comeths forceps, made so that they hold the cover-^^aas horiaomloBjf
when laid on a table. (3 ) Two platinum wires fixed to the end of glass rods. (4) Sterile
swabs (which are said to be obtainable from any medical officer of healtii). To make
them, twist a piece of cotton wool round the end of a stiff copper wire about 8 inches
long. Placo this in a test-tube, and plug its mouth with cotton wool. The end of

§ 987 ] CLINICAL BACTERIOLOQ Y-^SPUTUM 901

the wire should pass through the plug. The tube, with its contained swab, should
then be sterilised by heat. (5) Stains — methylene blue, eosin, oarbol-fuohsin. Gram's
stain, Leishman's stain, and other reagents. (6) A good microscope, including a
jV inch oil-immersion lens. (7) Wright's capsules (vide Fig. 106, § 387) are used for
oGtaining a sample of blood or serum for the Widal test. For bacteriological examina-
tion of the blood a sterilisable syringe is required. (8) A few tubes of nutrient media,
such as gelatin, agar, ascitic agar, serum agar, and blood serum, and a small incubating
oven are useful in many instances.

Mbthod of ExABfiNATiON SUTTABLB FOB Clinioal Woek. — (1) With a looped
platinum wire, which has been thoroughly cleansed by heating in the Bunsen burner
or spirit flame, select a minute portion of the material to be examined, and smear
this on the glass slide with the end of the wire. A thin film is thus formed. If the
material be too thick, dilute it with a drop of sterilised water. (2) Let the film dry
in the air, or by holding it high above the flame, and fix by passing it rapidly through
the flame three times. (3) Put a drop or two of the selected stain (previously filtered)
on the cover-glass, or float the cover-glass, film downwards, in a watch-glass containing
the stain. The time of leaving the film in the stain depends on the stain employed,
but in most cases one to three minutes is sufficient. (4) Rinse the oover-glass thor-
oughly in water, and dry by blotting-paper or gentle heat high over the flame. A
drop of cedar oil is placed on the cover-glass, and the oil-immersion lens employed.

MotUe Organisms may be examined unstained, and their movement readily seen.
Place a drop of tap water or bouillon on a cover-glass, and touch it with the platinum
wire, which has previously been dipped in the material to be examined. The glass
may be placed over the hollow of a hollow slide, thus forming the ** hanging-drop ";
but the movements can be as readily seen in the hollow or cell formed by drawing a
ring of vaseline round the edge of the cover-glass. The method of '* dark-ground
illumination " is the best for accurate observation of living and unstained baioteria.
It is also employed in examining scrapings for the spirochadte pallida. A parabolio
condenser fits into the same position beneath the microscopic stage as does the
ordinary condenser. The material to be examined is spread on a thin slide and
covered with a cover-glass. The slide is placed in the usual position, with a drop of
cedar oil on the under surface, in contact with the condenser, as well as on the upper
sur^use in contact with the oil-immersion lens. ANemst lamp or other good light
may be used. The best lens is the apochromatio 2 mm. and the ^ oil-immersion
flnorite lens. The bacteria or spirochetes appear as brilliantly illuminated against
a dark background.

Oram's Method. — Oeitain organisms possess the characteristic reaction that their
stain is fixed by iodine. Place the cover-glass, film side downwards, in a solution of
aniline-gentian-violet for five to eight minutes. This is prepared by adding 1 part
of aniline oil to 20 of distilled water, shaking thoroughly, and filtering the mixture.
To this add drop by drop a concentrated and filtered alcoholic solution of gentian
violet, in the proportion of 1 part of aniline water to 9 parts of the stain. (2) Place the
film in a solution made up of 1 gramme of iodine and 2 grammes of potassium iodide
in 300 c.c. of water. This acts as a mordant, and fixes the stain in the microbe.
The film becomes black. (3) Place the film in alcohol till it becomes a faint grey,
everything except the microbe becoming decolorised. (4) Wash, dry, and mount
as usual, or counterstain the other structures with dilute carbol fuchsin (1 in 10)
before mounting.

(a) The Sputmn is examined for tubercle bacilli, the pneumococcus, the
influenza bacillus, oidium albicans of thrush, the bacillus of plague in
cases of pneumonic plague, anthrax, the actinomycosis fungus, and the
micrococcus tetragenus (see below). Pyogenic organisms are found when
pus is present.

(1) The Tabarole BacilliiB (Plate IV., Fig. 1) is slightly curved, measuring 2 to 5 ft
long. Three go to the diameter of a red blood corpuscle. Often two lie together at
au angle, like the letter V. Clear spaces resembling spores and also darker stained

902 PATHOLOOIGAL FLUIDS AND CLINICAL BACTEBIOLOOY [§te^

knobs are often seen after staining. The tubercle bacillus is present in the sjnUum
in all but the earliest cases of active pulmonary tuberculosis. It is usually most
plentiful in the thicker and most purulent part of the sputum. Take the minutest
possible portion, and make a thin smear on a glass slide by spreading with a platinum
loop, or by drawing the edge of a slide along the smear. Fix the film by passing
two or three times through the flame of a spirit lamp. The characteristic staining
reaction is that of the Ziehl-Nielsen method. Heat some strong carbol fuchsin in
a test-tube and pour it over the film ; allow to act for three to five minutee. De-
colorise in 25 per cent, nitric acid till the smear shows no pink colour after washing
under the tap. Put into alcohol (absolute, or methylated spirit) for five to ten
minutes. (This is especially necessary when examining a urine, as it may contain
other acid-fast bacilli, which, however, give up the stain in alcohol.) Wash in wat^-
and oounterstain for two minutes in LSfiSer's methylene blue. When the bacillus
is hard to find, as when few are present, use the antiformin method. Antiformin con-
tains lotio sodium hypochlorite (Squire) 92*5 c.c, sodii hydrate 7-5 grammes. It
quickly causes solution and destruction of all the formed elements (both tissues and
bacteria) in a discharge, with the exception of tubercle and other acid-fast bacilli.
Take 20 to 30 c.c. of sputum ; add 15 c.c. of ** antiformin *' and make up to 100 c.c.
with sterile distilled water. After two to five hours the fluid is oentrifugalised and
the sediment washed with normal saline solution. This sediment will contain the
T. B. gathered into clumps. The T. B., after this process, have not lost their vitality
— pure cultures may be made from them on suitable media.

Other microbes which stain by the Ziehl-Nielsen method are the leprosy and the
smegma bacillus, etc. Leprosy bacilli occur in clumps, never isolated like tubercle.
The smegma bacillus may readily be mistaken for tubercle in the examination of the
urine. To distinguish it, place the cover-^ass in absolute alcohol for three hours,
then a quarter of an hour in chromic acid. Stain as usual, and wash in alcohol.
after decolorising in acid. The smegma bacUlus is thus decolorised.

(2) The PneomococoiiB (Fraenkel's pneumococcus) (Plate rV.> Fig. 2) is a coccus
usually of lanceolate shape, often in pairs (diplococcus). sometimes in short chains.
A capsule surrounds it, which is less deeply stained in stained preparations, and is
absent in cultures. Sometimes more than two cocci occur within one capsule. They
cause croupous pneumonia, but are also found in healthy saliva. Select a rust-
colourcd part of the sputum when the disease is at its height. It is found in the longs
in the red hepatisation state of the disease. The pneumococcus is easily stained by
ordinary aniline dyes. It can also be seen by Gram*s method, which distingoisbes
it from Fricdlander's pneumo-bacillns (also found in pneumonic sputum), the latter
being decolorised by Gram. By the carbol-fuchsin method the cocci should be
deeply stained and the capsule a fainter red, or altogether unstained.

(3) The Inflvenia BacilliiB (Pfeiffer's bacillus) is found in the sputum and nasal
mucus of patients suffering from influenza. It occurs as a minute rod, not quite 1 ft long,
lying in pairs or groups, and may be mistaken for diplococci. It stains best with dilate
heated carbol fuchsin. It may also be found in the blood at the acme of the disease.

(4) The Micrococcoi TetrageniiB occurs as cocci in groups of four in a capsule. It
is found in the sputum coming from phthisical or bronchiectatic cavities. It stains
with the ordinary dyes and not by Gram.

(5) The presence of the Actinomycofis fungus is suspected whoi small sulphur-
coloured granules, visible to the naked eye, are seen in the sputum or in purulent
discharge from tumours. Such granules under the microscope are seen to consist
of a largo number of threads radiating out from a centre like a ^n, each thread having
club-shaped ends. They stain well with Gram*s method. The pus has a characteristic
greenish -yellow colour.

(6) A False Membrane occurring on the throat or palate must be
examined for the presence of the diphtheria badllns. Taking care not to
touch the lips, cheek, or mouth inside, touch the suspected patch with a
sterilised swab or brush, or remove a piece of the membrane with a
platinum loop or forceps. Transfer this to a sterilised test tube, or spread

Fl". 1.— TUBEIICLB BaCU

Fio. 3. — Stkektococuis Pvui

Fi(i. 2 — PszuMorocci.

Fki. 4.— Tvi-uoiii Baci!

§ «g7 ] CLINICAL BA CTERIOLOQ Y— DIPHTHERIA 903

thinly on a slide ; fix, stain, and examine. Frequently so many micro-
organisms are present that it is impossible to make out satisfactorily the
diphtheria bacillus. In such cases cultures must be made by inoculating
tubes containing blood serum or glycerinated egg, solidified (2 per cent;
glycerine), with the platinum needle or swab. On such media, kept at
body temperature, the diphtheria bacillus grows rapidly in characteristic
colonies of punctiform spots with opaque centres. The growths can be
examined under the microscope within twenty-four hours, sometimes as
soon as in nine hours.

The baoillus is known as the Klebs-LofSer baoillus. It is of variable size and shape,
average 2 yi. long. It is straight or slightly curved. Some of the rods are knobbed,
thicker at one end. Some stain uniformly, others irregularly. They lie in clusters,
never in chains. There are no spores. Streptococci are frequently found with it,
but are no index of the severity of the case. Loffler's methylene blue is recommended
as the most suitable stain, because by its use the characteristic beaded appearance
or polar staining of the rods is well shown ; but any other basic stain may be used. It
also stains by Gram's method.

Hoffman's pseudo-dipTUheria bcuiiUus resembles the true diphtheria baoillus, but it
stains more deeply, and has not the polar staining which gives to true diphtheria its
characteristic club shape. The best method of distinguishing the Klebs-Lofflcr
bacillus is by Neisser's method. There are two stains. The first consists of methylene
blue, 1 gramme ; rectified spirit, 20 c.o. ; distilled water, 950 c.c. ; and glacial acetic
acid, 60 c.c. The second, or contrast stain, contains 2 grammes of vesuvin in 1 ,000 c.c.
of distUled water. Immerse the film in No. 1 for four seconds ; rinse in distilled
water ; immerse in No. 2 for four seconds ; rinse in distilled water ; blot and dry.
Diphtheria bacilli will be stained brown with an occasional bright blue granule.

Vincent's angina is a condition in which a white membrane resembling diphtheria
forms on pharynx and tonsils (§110). Bacteriological examination reveals a spindle-
shaped long bacillus, sometimes Gram-negative and sometimes Gram -positive, to-
gether with a spirillum. The two organisms are always found together ; it is supposed
that they represent different stages in the life history of the same germ. It may be
cidtivated on ascitic agar under anaerobic conditions.

(c) Pleural Effusion may be examined after fixing and staining on a
cover-glass or a slide, the latter giving a larger area for examination.
Serous effusions show few or no germs : the diplococcus pneumonisB and
tubercle bacillus are almost the only germs which have yet been found in
a serous pleurisy. Sometimes in tuberculous pleurisy no bacilli are found.
The germs found in purulent effusions are the diplococcus pneumoniae
and the streptococcus and staphylococcus, and the tubercle bacillus.

{d) Pus obtained from any part of the body should be examined, micro-
scopically or by culture, for the following organisms :

Oram-poeilive. Ornm-negalive.

Staphylococci. Gonococci.

Streptococci. Pneumobacilli.

Pneumococci. B. Ooli communis.

Anthrax bacilli. B. Tjrphosus and Paratyphosus.

Diphtheria bacilli. B. Mallei (of glanders).

Tetanus bacilli. B. Pestis (of Plague).

Actinomycosis. Diplococcus Intraccllularis.

Micrococcus Oatarrhalis.

B. Influenzse.

904 PATHOLOGICAL FLUIDS AND CLINICAL BA0TERI0L007 [|

(1) Streptoooooi (Plate IV., Fig. 3) occur in long or short chains.

(2) Staphylooooci aro large cocci occurring in small groups or bunches. Both are
pyogenic organisms, and are found in pus in various situations. Thej stain with
ordinary dyes and with Gram's method.

(3) The Oonoooocuf appears as a diplococcus. the paired cocci facing each other
with concave surfaces. They arc usually found inside the pus corpuscles lying in
groups. They are most readily found in the pus coming from a gonorrhoaal urethral,
or conjunctival discharge. They stain with the ordinary dyes, and not with Gram's
method. It is well to use a counterstain, such as eosin, which stains the corpuscles
in which the gonocooci lie.

(4) Buboes may require to be examined for the bacillus of Plague (bacillus pestis).
The bacillus is short and thick, 2-3 /a long by 1*7 m broad. It often lies in pairs, and
so may be mistaken for a diplococcus. The pus discharged from buboes generally
contains no bacilli.

The Malignant Pustule due to anthrax can frequently bo shown to contain the
anthrax bacillus. In doubtful cases examine the blood (see below).

The purulent discharge from a tumour caused by the aotinomyces fungus contains
tiny granules, which are described above under the Sputum.

(e) It is difficult to examine the stools for any particular oi^nism
because of the enormous number of germs present. Two, however, may-
be mentioned here — the Cholera Vibro and the Amoeba of Dysentery.
Various kinds of bacillus coli may always be found.

The Cholera Vibrio (Koch's comma bacillus) is obtained from the mucoid masdee
in the choleraic stools, but in at least half the cases no definite result is gained by
simple staining methods, and the organism can be recognised only by submitting it
to a number of cultural and other tests. The vibrios are curved rods slightly shorter
than tubercle bacilli. They lie in rows, end to end pointing in one direction. They
stain with ordinary dyes, not by Gram's method.

The Amosba of Dysentery is a spherical body, sometimes of a pale greenish colour
refracting the light strongly. It is 30 to 40 /a diametsr, has a granular endo^asm
and a clear ectoplasm, and is motile. The amoeba should be looked for in the stools
at once while the discharges are still alkaline. The glass slides, cover-glass, and the
microscopic stage should be warmed. A drop of mucus from the stools, or a scraping
from the wall of a tropical abscess is diluted with warm saline solution and placed on
the slide. The amoeba will then be seen actively moving. The amoeba is easily
killed ($(^Q solution of quinine arrests the movement), and if examined when the
stoob are acid, the amoeba will have no movement.

(/) The urine may require to be examined for the tubercle bacillus, the

gonococcus, the typhoid bacillus, and the colon bacillus. The tubercle

bacillus is described under sputum, and the gonococcus under pus above.

The tubercle bacillus is sometimes very difficult to detect in urine. It is

best to draw oft the urine by a sterilised catheter to prevent the entrance

of the smegma bacillus. Stand the urine for twenty-four hours in a

conical glass, or centrifugalise it. Examine the sediment carefully,

staining, etc., as with sputum.

The Typhoid bacillus (Eberth's bacillus) (Plate IV., Fig. 4) is short, thick, and
mobile with rounded ends. It is 3 to 4 fi long, and 1 u broad, and is flagellated.
Sometimes several rods lie end to end. It may be very difficult to distingoish from
the baciUus coU communis, but is known by its characteristic cultuies. It st^ns
with ordinary dyes, and not with Gram's method. The typhoid bacillus is the cause
of enteric fever, and occurs in the spleen, in the blood, in the rose-coloured spots.
in the urine, and in the stools. However, one is not likely to succeed in finding them

{ e27 ] OLINIOAL BAOTEBIOLOO Y—WIDAVS REACTION 906

by miorosoopio examination except from oultore growths, and expert knowledge is
required to snooeed in obtaining a pure culture.

The Colon Bacillas (b. ooli communis) may also be found in the urine, causing
cystitis, pyelitis, and pyelonephritis, apart from any other pathogenic germ. It
has also caused suppurative peritonitis. It closely resembles the typhoid bacillus,
but is somewhat shorter. It is motile, but has fewer flagellie than the typhoid bacillus.
It stains with ordinary dyes, not with Gram's method. It can only be distinguished
by cultural and other tests.

g. The Blood may be examined for certain parasites — malaria, trypanosoma, filaria.
kala-azar, etc. (§ 390). The pyogenic organisms (see table, p. 903), the typhoid
bacillus, the anthrax bacillus, and the micrococcus of Malta fever have been found
in the blood. The spirillum of relapsing fever is always present in the blood in the
febrile periods. Some are difficult to detect unless a large quantity of blood is
available. The blood may be drawn off with a hypodermic syringe from the spleen
or liver for the detection of the parasite of Kala-azar.

In suspected oases ol Anthrax where it has not been possible to find the bacillus
in the pustule, examine the blood. The bacillus is one of the largest, about 6*2 /t long.
When cultures are examined, spores are seen inside and around the filamentous seg-
ments. It stains with the ordinary dyes and with Gram's method.

The Microcoooai Meliteniii is the cause of Undulant fever. It is a minute coccus
(i It), motile, sometimes lying in chains. It can be obtained by puncturing the
spleen with a fine sterilised hypodermic needle with due precaution, and withdrawing
a little blood. This is a dangerous method, and the presence of the disease may be
diagnosed by the agglutination tests. The coccus stains with the ordinary dyes,
and not by Gram's method.

Widal'i Senim Reaction. — This test depends upon the fact that a patient suffering
from infection with Bacillus tjrphosus possesses in his blood serum an abnormal
amount of agglutinins for that micro-organism. The same holds good in certain
other infections — e.gr., paratjrphoid infections, cholera, dysentery, cerebro -spinal
meningitis, etc. — ^in all of which conditions one finds an excess of agglutinating sub-
stances against the particular micro-organism which is the cause of the disease. Here
we shall only deal with the agglutination test in typhoid, the so-called '' Widal
reaction." In typhoid fever the reaction may be present as early as the third day,
but generally not till the seventh to tenth, but persists afterwards for several months,
or even years. Typhoid ** carriers " may give a positive Widal reaction, though
showing no signs of the disease. To perform the test, blood is collected from the
patient's finger by means of Wright's capsules (see § 387, Fig. 106), and allowed to
stand. The serum separates out, and is used for the test. By breaking off the end
of the capsule access is obtained to the serum, just as is done in estimating the opsonic
index (see § 387). The test may be performed in the following ways :

(1) The Hanging Drop Method. — ^The serum is transferred to a watch-glass. A
platinum wire loopful is placed on a coverslip, and to it are added 9 loopfuls of normal
saline. The drops are then mixed so that the dilution is 1 in 10. A loopful of this is
transferred to another coverslip, and to it 9 loopfuls of salt solution are added. The
second serum dilution is I in 100. A loopful of a twenty-four-hour-old broth culture
of typhoid bacilli is now put on to each of two clean coverslips. To the first a loopful
of the serum, diluted 1 in 10, is added, making a dilution 1 in 20 ; to the second a
loopful of the serum, diluted 1 in 100, making a dilution of 1 in 200. Each coverslip
is inverted over a hanging drop chamber, the edge having been vaselined, to prevent
evaporation, and the bacilli are watched under the high power of the microscope.
Within half an hour with a dilution of 1 in 100 the bacilli should run into clumps
and become inunobile. The reaction may be regarded as positive only if the bacillus
is agglutinated by the patient's serum in a dilution of at least 1 in 100. Occa-
sionally the sera of healthy persons may agglutinate the B. typhosus in dilutions
of 1 in 60.

(2) Sedimentation Test. — ^This is best performed by means of Wright's pipettes
(see Fig. 170). A mark is made on the lower end of the pipette. nlH)ut 1 inch from

906 PATHOLOOIOAL FLUIDS AND CLINICAL BACTERIOLOOT [{tt7

tne extremity, with a soft aniline pencil. By means of the rubber oap normal saline
is drawn up to the mark. This quantity is now blown out on to an ordinary ^Ums
slide by squeezing the cap, so that it forms a pool at the left-hand top comer. This
process is repeated until six such pools, each containing an equal quantity of normal

saline, are placed on the slide in two rows of three each. The
patient's serum is now drawn into the pipette up to the mark, and
this is now blown out again, and mixed with the saline in the first
pool, giving a dilution of serum of 1 in 2. This mixture is drawn
up to the mark and blown out into the second pool, giving in this
case a dilution of 1 in 4. This is repeated for the third, fourth, fifth,
and sixth pools, giving dilutions respectively of 1 in 8, 1 in 16, 1 in 32,
and 1 in 64. The next step is to take an emulsion of a twenty -four
hours' culture of typhoid bacilli. This is also drawn up to the mark
on the pipette and added to the first pool, the process being repeated
for all the other pools in turn. The pools now contain dilutions of
serum of 1 in 4, 1 in 8, 1 in 16, 1 in 32. 1 in 64, and 1 in 128.
Samples of each of these are now drawn up into t^e pipette. The
1 in 4 dilution is drawn up to the mark, and a bubble of air let in ;
then the 1 in 8, then a bubble of air, and so on in turn the 1 in 16,
1 in 32, 1 in 64, and 1 in 128 dilutions, a bubble of air intervening
between each. The pipette is then seeded, and stood aside in an
upright position for half an hour. It is then examined by the naked
eye. In the dilutions in which clumping has occurred a definite
sediment will be seen to have settled at the bottom of the column,
whilst if no clumping has occurred, in any particular dilution, that
dilution will be uniformly cloudy. If the reaction is posiiivt, tkc
1 in 64 diltUion should dump definitely in half an hour.

(3) Either of those tests may be employed, using emulsions of dead
bacilli. Sir A. £. Wright has described^ how the practitioner can
carry about with him, without risk, dead cultures of both typhoid
and Malta fever organisms, and thus readily diagnose the prtsenc? or
absence of these diseases.

Wasiermann Reaction. — Within the last few years this method of
sero-diagnosls has acquired a position of extraordinary importance on
account of its great reliability in the diagnosis of syphilis. With the
best technique (as perfected by Dr. Boas in Copenhagen) the result
of the examination is absolutely conclusive — a positive reaction
indicates syphilis and a negative reaction excludes the diagnosis of
syphilis. Unfortunately, the technique is difficult and the process is
tedious, and so it has come that many substitutes have been offered
in order to simplify the experiment. So far not one of these baa
justified itself. The diagnosis of syphilis is a matter of too vital
importanca for the patient to allow of it being founded on a reaction
which gives a percentage of correct results. The use of the current
simplified methods is greatly to be deprecated ; a Wassermann re-
action, to have any value, must be performed by an experienced
worker and one who is able to appreciate all the sources of fallacy. For
descriptions of the rationale of the experiment and of the technique
the student is referred to textbooks on Immunity.
The Oerebro-Spinal Fluid (see § 626).

'^'

L-.-.-t'

•d

u
c9

P.
P.

H
CO

H
B
O

i «

r^^ t

:^S.

t^!

I. For the SpirochsBte Pallida (Treponema Pallidiim). the edge of

the primary sore, a condyloma, mucousr patch or early ulcerative

syphilitic lesion is gently scraped with the edge of a microscopic slide or sterile scalped

until it begins to bleed. The blood is then mopped oil with some absorbent material

until it is replaced by a drop of serum. A film of this serum is made. The spirochxta

1 BriL Med, Joum, 1897. vol. i.. p. 1214.

J W ] OLINIOAL BAOTERIOLOO Y 907

pallida may be ezamiDcd by the method of ** dark ground illumination " or by staining
methods. It may bo stained by Leishman's method, but a better method is by
Giomsa's stain. One drop of this stain is added to 1 c.o. of tap-water, which is then
spread over the film, or the film may be floated face downwards in the stain. The
staining takes from five to twenty-four hours. The excess should then be washed
out by tap-water, and the film dried and mounted in the ordinary way. A
description of the organism is given under Syphilis (§ 404, and Fig. 117).

Another good and also very simple method is that with Chinese ink. A drop of
material from the " scraping " to be examined is put on the centre of a slide, and one
drop of ink (" chin-chin ink,** Gunther Wagner) is also laid on the slide ; mix together.
A smear is made, as one smears a blood film, by drawing the end of another glass slide
along the preparation. After drying (without heat), the smear is ready for examina-
tion. Spiroch»t8B and other micro-organisms stand out as clear, glibtening white
objects against the dark background.

FORMULA

(referred to as F. iu the text)

OF USEFUL PRESCRIPTIONS.

The J ro portions given are those /or one advlt dose unless

otherwise stated.

(1) Balneum Alkalinum.

Add two large handfuls (8 om.) of common
washing soda to 30 gallons of water at 95 F.
The patient remains twenty minutes in first
bath, and the time is gradually increased up
to forty-five minutes. Put to bed in bUtnkets.

Valuable for chronic rheumatism — daily for
six weeks. At first the pains are increased.
Also useful for chronic eczema.

(2) Balneum Creol. vkl Picis.

B Creolin Sss. to 3ij. or Liquor Car-

bonis Dcterg. . . 3i- *<> 3iv.

in 20 to 30 gallons of water, well stirred.

Useful for pruritus, prurigo, chronic eczema,
and all itching affections.

(3) Balneum Sulphuris.

B Potass. Sulphurat. . Ju-
Acid. Acet. dil. (or vine-
gar) .... Oss.
Warm water . 20 to 30 gals.

(4) Balneum Vapobis Hydearo.

E Hydrargyri Subchloridi

3ss.

Volatilise beside \ pint of water for twenty
minutes in a Lee's lamp. Seat the p^ent
in a cane-bottomed chair. Tie the curtain
round the neck, and put a blanket over the
shoulders. Light the lamp, and place it be-
neath the chair. Leave the patient in from
twenty to forty minutes.

(5) Shower Bath.

See that the shower is the required tem-
perature' before placing the patient in the
curtain, then turn on suddenly, because the

I Cold, 60** F. ; tepid. 76*» F.

chief therapeutic value of the shower U byjtj
shock. It should not be given where martod
heart disease exists. Valuable in hjatciia
and neurasthenia.

(6) HoT-AiR Bath.

Remove the clothing and lay the patieot in
a bUmket, adjust the wicker f»«ne'ro«'^^J
cover it with three or four blankets, ™«J
should come up well under the chin. Ligbt
the torch under the chimney, and let it cog;;
Unue to bum until the patient perspires very
freely. He may remain for fifteen <* ^f'*?!!
minutes longer. The temperature innde tlie
wicker work should be between 170" and
200'' F. Valuable in renal disease.

Collunaria.— Nasal douches. ShouW be
used at a temperature of about IOC* F. Haff
a tumblerful to be injected along the n<wfo{
each nostoil night and morning. Xbe pato«t
should be directed not to blow the noee f ofdUy
immediately afterwards.

(10) Col. Pot. Chloe. Comp. (C. L.
Throat Hosp.).

B Pulv. Pot Chlor. .
Pulv. Boracis

Soda? Bicarb. . »» gr. »]•

Pulv. Sacch. Alb. . . ad 3j.

To be added to half a tumbierfnl (sv.) of
water. Useful in all forms of chronic lidnitis.

(II) Collunarium Ac. Carbou

(vel BoBACis).

3j. of Ule Olyoerinum GarboL or Boracis
(B.P.) to 10 fluid o«. of watei.

(13) Enbma Hazslikjl
Hazelino and water . Of each 1 o*.

Administered slowly by means of a glyeeriBe
syringe tat internal i^lea.

908

FORMOLJE

909

TaMe Show^ig Difference in Doeage of die Chief
Standardized and Potent Pieparations of die British
Pliarmacopoeia of 1898 and the United States
Pharmacopoeia of 19^.

B. P. Dote

U. S. P. DoM

Aconite Root

Fluid extract

Tincttire

Belladonni Leavf. . .

Extract

Tincture

BeUadoima Root

Extract (alcoholic).

Fluid extract

Tincture

QnchoiM

Fluid extract

Tincture

Coca

Fluid extract

Colchicum Corm

Extract

Cokhicum Seeds

Fluid extract

Tincture

Conhim

Fluid extract

Tincture

Hydrastii

rluid extract

Tincture

HypBcyamut

Extract

Fluid extract

Tincture

Ipecacuanha Root. . . .

5 to 15 minims,
i to 1 grain....

i to 1 grain. . . .
5 to 15 minims.

5 to 15 minims.. ,
i to 1 fluid dram.

to 1 fluid dram,
to 5 grains. . . . .
i to 1 grain ,

5 to 15 minims,

i to 1 fluid dram.

5 to 15 minims.. ,
i to 1 fluid dram.

2 to 8 grains.

Fluid extract.

Nux Vomica Seeda.

Extract

Fluid extract. . .

Tincture

Opium

Extract

Tincture

Phjtotticma

Extract..

Tincture..
Pilocarpua (Jaborandi)

Fluid extract

Tincture

Stramonium....

Extract

Fluid extract

Tincture ....

4 to 1 fluid dram

Expectorant, i to 2 rts.
Emetic, 1 5 to 30 grains .

Expectorant, I to 2 min .
Emetic, 1 5 to 20 minims

5 to 20 grains

1 to 4 grains

i to 1 grain

1 to 3 minims

5 to 1 5 minims

4 to 2 grains

I to 1 grain

Repeated, 5 to 1 5 minim
Single, 20 to 30 minims .

i to 1 grain.

5 to 15 minims...
i to 1 fluid dram.

(From seeds). } to 1 gr

(From leaves), 5 to 15
minims

1 grain.
1 minim.
10 minims.

1 grain,
i grain.

8 minimn.
} grain.

1 minim

15 grains.
15 minims.

1 fluid dram.
30 grains.
30 minims.

4 grains.

1 grain.

3 grains.

3 minims.
30 minims.

3 gruins.

3 minims.

30 grains.
30 minims.
1 fluid dram.

4 grains.
1 grain.

3 minims.
30 minims.
Expectorant, 1 grain
Emetic, 15 grains.

Expectorant, 1 min.
Emetic, 15 minims.

15 grains.

1 grain.

I grain.

1 minim.
10 minims.
1^ grains.

\ grain.

8 mininn.

1} grains,
t grain.
15 minims.
30 grains.
30 minims.

1 grain.
* grain.
1 minim.

8 minims.

FORMULJE

909

(14) Enema Nut&ibns.

(a) Peptonised milk, 2 to 4 oz.

(6) Strong beef- tea, 2 oz., and meat
joioe, 1 oz.

(c) One egg, 1 oz. brandy. 2 oz. strong
beef-tea or 2 teaspoonfuls of meat
extract ; and 1 tcaspoonful of
BoUook^s acid glycerin of pepsin ;
mix and divide into two enemata.

These may be administered alternately.

(15) Qabo. Acidi Carbou o Co-

OAINA.

E Acidi Oarbolioi . . • 3J*

Cocain» Hydroohlor. . . gr. viij.

Glycerini Boracis . . ^ss.

Aquam Rosas . .ad ^xij.

For acute pharyngitis and laryngitis.

(16) Garoarisma Acidi Tannici.
B Glycerini Acidi Tannici . 3J'

Aquam . . . ad 5j-

For relaxed throat and to check bleeding
after tonsillotomy.

(17) Garoarisma Boracis Com-

POSITUM.

B Pulvcris Aluminis
Pulveris Boracis .
Tinctur» MyrrhsB .
Mellis .
Aquam .

aa gr. vijss.

mv.

gr. X.
ad 5j.

(18) Gaboabisma Chlorini.

B Potassii Chloratis . . 5U*

Acidi Hydrochlorici For-

tioris . . . • 5J*

Cork and set aside for five or ten minutes,
then add —

Glycerini . . . 3^^*

Aquam .... ad S^j*

To be freshly prepared. A very prompt and
efflcadons remedy for scarlatinal and diph-
theritic sore throat, hospital sore throat, and
follicular tonsillitis. For children it should be
applied wit^ a brush every two hours.

(19) Garoarisma PoTASsn Chlo-
ratis.

Br Potassi CMoratis . 3^8^.

Aluminis .... 3^*
Aquam . ad ^x.

(20) Glycbrinum Carbolici Fort.

B Aoidi Carbolici . . . 3iU*
Glycerini . . . . 3J'
For applloatioQs in endocervicitiB.

(21) Glycbrinum Ferri.

B Liquoris Ferri Percliloridi . 3*^.
Glycerini .... 3*S8.
Aquam . . ad 5j*

To paint the tonsils in recurrent tonsillitis.

(22) GUTT^ AURIBUS.

B Plumbi Acetatis . • gi^- J*

Tinctura) Opii . . • 3J-

Glycerini . . • SJ*

Aquam RosaD . . ad Jj.

Used warm for inflammation or pain of
the external auditory meatus.

Glyc. Ac. Carbol. (B.P.) answers the same
purpose.

(23) GuTTJB Dkntibus (Dr

B Olei Caryophylli .
Etheris
Tincturse Opii
Glycerini .

Gayc).

niv.

n\xv.
ll(xx.

n\xx.

To drop in a painful hollow tooth, or to
apply on cotton- wool. Washing out the
mouth with warm carbolic lotion (1 in 100)
often relieves toothache.

(24) Injectio Hydrarg. Hypoderm
(Durham).

B Ammonii Chloridi
Hydrargyri Perchloridi
Aquam Destillatam

gr. viij.
gr. xvj.
ad 5j.

Dissolve. v\\. contain i gr. Hydrargyri
Perchloridi. Inject mi. to uiv. into the
muscle of buttock or shoulder every seconii,
third, or fourth day.

Another formula consists of Hydrarg. Suc-
ciniroide, 2 % with Cocain. Hydroch. \ % :
dose, 20 to 30 la. It is less painful and
equaJly efficacious.

(25) Injectio Morph. cum AtropinA.

B Atropinso Sulphatis . gr. |

MorphinaB Acetatis . . gr. viij.
Sol. Ac. Carbol. (1%). . ad 3iv.

(niv. contain r.'n sr- and | gr. respectively.)

(27) Injectio Pilocarpine.

B Pilooarpinie Nitratis . . gr. v.
Sol. Ac. Carbol. ( 1 %) . . n\ 100.

Dose 2 to 5 ni. Kapld diaphoretic, nij.
useful to reduce arterial tension. Also used
in nerve deafness, gr. ^'o gradually worked up
to gr. i daily, resting for two hours afterwards
(Field, Brit. Med. Joum., 1889, vol. i., p. 471 ;
and 1890, vol. i., p. 1125).

910

FORMULM

(28) Injkctio STRYcnNiViE Ck).
B Strychninse Sulph. . . \

Atrop. Sulph.
Aoidi Borici
Acidi Carbol. (pur.)
Aquam DestillatAm

1
1
ad 100.

niv. M often m required, to relioTo the
proetrmtion and bodily discomfort in vascular
dilatation, such as occurs in neurasthenia and
morphia craving.

(30) LivcTUs Communis.

E Oxymellis Soill» . • 3iJ*
Sjrmpi Tolutani . . • 3U»
Tinctursc CamphorsB Com-
posite .... 3J'
Aquam Destillatam . ad Jj.

Dose. — I a teaspoonful for bronchitlc cough*

(31) L1NCTIT8 Sedativus.

B Liquoris Morphin» Hydro-

chloratis . . . n\z!.

Acidi Hydrocyanici Diluti . n\viij.

Acidi Hydrochloric! Diluti . n\ xvj.

Glycerini . . . . 3*^'

Aquam Destillatam . . ad $j.

Dot. — ^i. Relieves tJie cough of phthisis.
A teaspoonful in a wineglassful of wat^r may
be sipped every Ave minutes until the cough
is relieved.

LTNIMENTA.

(32) LiNIMBNTUM AmMONLS Co.

B Olei TercbinthinsB
Dquoris Ammonia)

tioris
Saponis Mollis .
Camphorse .
Spiritiis Vini Methylati
Aquam

For

3x.

3iv.

3v.

gr. 80.

3»J.
ad ^x.

A stimulating
Elliman's.

embrocation, resembling

(33) Lin. Bellad. cum Chlorof.

B Lin. Belladonna, Lin.

Chlorof ormi . • »* 3J'

Very valuable for lumbago and other rheu-
matic affections ; sprinkled on lint. Do not
cover with oil-silk, or It will blister. A very
expensive liniment, which for hospital pur-
poses can be made equally well with Lin. Tere-
binth instead of Lin. Chlorof.

(35) Lono Alkalina Ofiata
(FuUer).

B Potassii Oarbonatis . gr. 200.

Liquoris Opii Sedati vi . . IT\ 40U.
Glycerini .... Jx.
Aquam .... ad Jx.
Apply warm to painful rheumatic Joints.

(36) LoTio Calamine
B CalaminsB

Zinci Oxidi
Glycerini .
Liq. Caiois .
Aquam Destillatam

gr
3ss.

3»J.

ad 5j.

(37) Lono Calcis cum Oleo
(Oarron oil).

B Acidi Carbolici . , . m x.
Liquoris Calcis .

Olei LJni . . . . aa 3u-
Mix well. Invaluable for bums.

(38) Lono Capillaris.

B Tincturse Cantharidis . . 3^^

Liq. Ammon. Fort. . 5**®-

Glycerini . . . . 5***-

Aquam . . ad sj.

Rub into the head night and morning for
baldness.

(39) Lono Creolin.

Creolin 3j. to Oj. of water, to wash skin
diseases, before applying ointments.

If the skin is dry and harsh, add Glycerin
.^ii. to Oi.

(40) Lono Evapobans (vel Frigida).

B Liquoris Ammonii Acetatis

Spirit&s Vini Methylati . aa Jv.
Aquam . ad 5^.

Local application for acute gout, sprained
Joints, or headache. Invaluable for iiuect
bites and stings. N.B. — Must not be covered
by oU-silk.

(41) Lono KsROsurjc

B Kerosene • 5u-

Olive OU . . .

For pediculi capitis.

(42) Lono Plumbi cum Zinco.

B Lot. Plumbi Subacet. Dil. . 3J*

Zinci Oxidi . • gi** ^^^

Glycerini . . 3**-

.\quam . ad 5J*

Invaluable for acute

FORMULA

911

(43) Lono Hyd. cum Acid. Caabol.

E Hyd. Perohlor. . • gi"* ^'

Aoid Carbol. . . n\zz.

Glycerini . . . . S^s*

Sp. Vini Rect. (or Meth.) . 3 J-

Aquam . . . . ad ^j*

(44) LoTio Saponatus Kalinus
(Hebra).

B Saponis Viridis . . • 5j.
Spir. Vini . . . • Jij*

DlBsolve by gently heating, filter, and add
01. Berg, and 01. Lav. iia nixv. For cleansing
the head from Scborrhoea.

(45) MiSTURA Ammon. Chlob. Co.

B Ammon. Chlor. . . • Rt. xv.

Liquoris Morph. Hydrochlor. n\ v.

Aquam Chlorof. . . . ad 5i'
'^ ; 4tl8 horis in facial neuralgia, i .

(46) Mi.ST. Aperiens Epfervesckns.

No. 1.

B Sodii Bicarbonatis
SodsB Tartaratee .
Potassii Tartratis
Aquam

No. 2.

B Acidi Tartaric
Aquam

gr. XXX.

gr. xl.
gr. xl.
ad 5j.

gr. XXX.

• ad 5j.

(47) MiSTURA Bromidi et Iodidi.

B Potassii Iodidi . . • gr. v.

Ammonii Bromidi . . gr. xv.

Spirit Ammon. Aromat. . Tl\xv.

Syr. Aurantii . . • 3J'

Aquam . . . ad ^j'

(48) MiSTTTRA Bucnu Aj.kalina.
B Potassii Nitratis . . • gr

Potassii Bicarbonatis
Sp. Etheris Nitrosi
Tincturse Nuois Vom.
Tinctured Hyosoyami
Inf. Buchu

gr. XV.
n\xx.

n\v.

n\xx.
ad 5j.

A valuable diuretic mixture. Also for
csrstitls and prostatic retention.

The Buchu infusion should be freshly pre-
pared. The beet way to administer this drug
18 to procure some Tix. packets of the leaves -
place a packet in a pint jug, previously warmed,
add 1 pint of boiling water, stir, and, after
standing one hour, decant. One pint to be
taken in twenty-four hours.

(49) Mistitra Calcis Chlobidi.

B Calois Ghloridi . • gi^- ^^•

TinoturaB Aurantii . - H-

Aquam Chlorof. . . . ad ^j.

Valuable for prurUus from anv cause.^
Should be given three times a day after meals
in gradually increasing doses. In JuBtnorrhage,
uterine or pulmonary, should be given every
two to four hours.

(50) MiSTURA Capsici.

B TinctursD CJapsioi . H^iij.

TinoturaB Nucis Vomio83 . n\v.

Spiriti3is Chlorof ormi . n\xv.

Aquam Monthsa Piperitae . ad $j.

For flatulence. An excellent " pick-me-
up " for alcoholics.

(51) Carlsbad Mixture.

B Sodii Bicarbonatis
Sodii Chloridi
Sodii Sulphatis .
Magnesii Sulphatis
Aquam Mentha) Piperitae

gr. XV.
gr. v.
gr. XXX.

3J.

ad 5j.

A morning purgative draught for plethora,
obMity, gout, and rheumatic gout.

(52) MiSTURA Cascarill/E Com-

POSITA.

B Tincturse Nuois Vomioio . 11^ v.
TinoturaB ScillaB . . . T1\x.
Oyxmel Scillae . . n\xx.

Infusum CascarillaB . . ad ^j.
Chronic bronchitis and emphjrsema.

(53) MiSTURA Diaphoretic A.

B Spirit^ Etheris Nitrosi . S^s.
Liq. Ammonii Acetat. . 5U'
Aquam Camphorae . . ad ^j.

Diaphoretic and febrifuge.

(54) MiSTURA Digitalis Co.

Tl\v.
gr. uj.
gr. V.
l^v.
ad 5j.

For mitral disease with failing compensa-
tion.

B TinoturaB Digitalis
^Ammonii Carbonatis .
Potassii Nitratis
Tincturae Nucis Vomicae
Aquam Chloroformi .

(55) MiSTURA DiURETICA.

B Potassii Acetatis . . gr. xv.

Spiritiis Etheris Nitrosi . n\xv.

Spirittis Juniperi . . T1\xxx.

Decoctum Scoparii . . ad Jj.

^ The pathology of itching and its
treatment by large doses of Calcium
Chloride.— The Laiicel, August 1, 1896.

912

FORMVLM

(56) MiSTXTBA Ether Ammon.
B Sp. Ammonia) Aromat. . Tl\xx.
Spirit <is Etheris . . . Tl\xx.
Spiritus Chloroformi . . UV^x.
Aquam . . . ad 5i*

For cardiac failure. More efflcacions if
accompanied by liypodermic Injection of Liq.
Strychn. miij.

(67) MiSTURA EXPKCTORAN'S.

B Ammonii Carbonatis . . gr.

TinotursB Scillae .
Spirits Etheris .
Tincturaa Strophanthi
Infusum SencgsB

nixv.
n\xv.
ITliij.
ad 5i.

For acute broncliitls in tlie second stage.
(58) MiSTURA EXPECTORAKS

Infantilis.

B Ammonii Carbonatia . . gr. |

Tincturffi ScillsB . • ^ xx.

Vini Ipecacuanhse . . n\iv.

Aquam . .ad 3J-

For a child one year old. Given every hour
in broncho-pneumonia, it may cause emesis,
which is beneficial.

(69) MiSTURA Ferri Laxans.

B Ferri Sulphatis . . • gr. ij-

Magnesii Sulphatis - 7>^'

Acidi Sulphurici Diluti . niiij.

Essen tiaa Menth» Piperita . n\v.

Infusum Calumbffi . . od $j.

(60) MiSTURA Fn.icis.

B Ext. Filicis Maris . • 3J*

Syr. Zingib. . . • 3J'

Tinctur» Quillaiaa . . %Ba.

Aquam Chloroformi . . ad 5 iss.

(61) MiSTURA Hydraroyri

BiNIODIDI.

B Potassii lodidi .
Liq. Hydrarg. Perch. .
Tinotur« Cardamomi Com

posita)
Aquam

gr. V.

nVxv.

ad 5j.

(62) MiSTURA Oi.EI MORRHU*.

B OleiMorrhuffi . . . Jss.

Liquoris Calois .
Liquor. Calais Sacch.
Pulv. Trag. Co. .
Olei Caryophylli
Olei Cassia)

3"J-
ll\xxxvj.

gr. vj.

nii

(63) MiST. POTAS. CiTRATIS

Effervbsckns.

No. 1.

B Potassii Bicarbonatis . • gT; ^*-
Aquam -Si-

No. 2.

Aoidi Qtrioi . . • gr- *^-
Aquam .... 5®-

An agreeable effervescing vehicle for quinine
and other drugs.

(64) MiSTURA RiciNi Calcis.
B Olei Ricini . . S"-

Liquoris Oalcis .

TinctursB Quillaiaa

Syrupi

Olei Mentha Piperita

5»-
n\xv

nij.

3i. every hour for diarrhoea and imbfealtby
stools in children.

(65) MiSTURA Sedativa Infantius.

B Ammonii Bromid. . . gr. iv.

Tinctura Belladonna . . ll\iv.

Glycerini .... IRx. ^

Aquam . . ad 3J-

A harmless sedative for a chfld of one year
old.

(66) MiSTURA Stomachica.

B Magnesii Carbonatis . • gr- ^
Sodii Bicarbonatis . . gr. xv-
Acidi Carbolici pur. . . IHJ.
Tinctura Rhei Composita . lUxv.
Infusum Oalumba . . ad Jj.
Tea-drinker*8 dyspepsia and pyrosis.

(67) MiSTURA Strychnin-*.

B Liq. Stryoh. Hydrochlor. . Riij.
Acidi Nitro-Hydrochlorici

DUuti .... Ry.

Tinotura Capsici • ^j-

Tinctura Lavand. Co. . . IRv.
Aquam ... .ad ^j.
The tonic for old age.

(68) MiSTURA Pro Tussl
B Tinctura Oamph. Co. . - Rx.

An agreeable cod-liver oil emulsion.

Vini Ipecacuanha
Oxymellis Scilla .
Aquam Anisi

For chronic bronchitis

adjj.

FORMULA

913

(70) NsBULA Alkalina.
B Sodii Bioarbonatis . gr. xij.

Boraois
Aoidi CSarbolioi
Qlycerini .
Aqnam

gr.

XI J.
iv.

nixi.

ad 5J-

To be sprayed into the anterior naree for
oiena and ulceration.

(72) Nbbxjla Zinci Chloridi.

B Zinci Chloridi . . gr. z.

Aoidi Hydroolilorioi Diluti . I1\ j.
Aquam Destillatam . ^ j.

Sprayed into the anterior nares for otironio
rhinitis ; may be also used as a throat spray
for olironic laryngitis. Or. xx. to \i. outs
short an attack of acute larsmgitis, and should
be used as follows : Pull the tongue well for-
ward and spray interior of larynx ; apply cold
compress to throat at night, and in the morn-
ing let patient inhale chloroformi nixx., Tr.
Benzoin Co. ad ^i- in a pint of boiling water
every few hours. (See Vapores, p. 915).

(76) Pasta^ BssoBdK 0)MP.

B Resorcin • SJ*

Zinoi Ozidi . 5^j*

Pulv. Amyli S^j'

PetroL Moll. • SJ*

Mix welL A valuable protective paste. For
chronic conditions, Salicylic or Carbolic Add
(20 to 00 grs.) may be added.

(76) Pasta Sulphxtbis.

B Sulph. Preoipit. . • SJ*

Zinci Oxidi . . * 3J*

Silioious earth . .3^*

Adep. Benz. . • Sj>

A protective paste for chronic skin diseases.

(77) PiGMSNTUH Aoidi Chbomici.
B Acidi (ITliromici . . . gr. 50
Aquam Destillatam . ad 5 J*

To paint unhealthy ulcers.

(78) PiOMBiiTXJM Acidi Salioyuol

B Aoidi Salicylioi . • 3 J*

Extraoti Oannabis Indiose . gr. viij.
CoUodii Flexilis . • 3^j-

Athens . . • 3u*

Paint on every night to remove corns.

(79) PiOMENTUM Cadis.

B Ol. Cadi .... 3j.
Spiiitiis Vini Meth. • SJ*

Sapo Mollis . ' ih

For psoriasis of scalp and lupus erythe-
matoBOs.

^ Pastes are stiff ointments which act
as proteotives and drying agents.

(80) Piqmbntum Cbbosoti.

B Creosoti .... 11\ij.

Acidi Salioylici . • gi** ^i^^

^ Collodii . . • SJ*

Very efficacious for lupus erythematosus.

(81) PlOMXHTUM lODI COMPOSITUM.

B lodi . . 3J*

Aoidi Oarbol. liq. 3

IV.)

weight.

Bub together in a warm mortar and dis-
solve, warming if necessary. Eesembles
Gostor's Paste. For intractable ringworm ;
apply once a week to the scalp vrith a hog's
bristle brush.

(82) Plastsb Mulls (Emplastra),

with composition as follows, are ob-
tainable at most large pharmaceutical
chemists :

(a) Empl. Ac. Salicylic. (5 to 15 %).
(6) Empl. Ac. SalicyL (5 %\ and Ac.

Carbol. (10 %).
(c) EmpL Ac. Salicyl. (10 to 50 %), and

Creosote (20 to 50 %).
{d) EmpL Hydrarg. (10 to 30 %).
(e) Empl. Hydrarg. (20 %), and Ac.

Carbol. (71 %).
(/) Empl. Hydronaphthol (5 and 10 %).
{g) Empl. Ichthyol (5 and 10 %).
{h) Empl. Ichthyol (10 %), and Chry-

sarobin (10 %).
(t) Empl. Resorcin (10 and 15 %).
(;•) Empl. Zinoi Ox. (20 %), and Sul-*

phur (1 %).
{k) Empl. Zinci Ox. (10 %), and Ac.

Salicyl. (6 %).
(/) Empl. Zinci Ox. (10 %), and Ich.

thyol (5 %).

(83) pilula asafostida com
Valebiawa.

B Asaf 0Btid» .
Zinci Valerianatis

Flatulence "

. gr. uj.
. gr. j.

** and the mani'

xuMouwaw. nervousness,
f eetations of nysteria generally.

(84) Pilula Digitalis Comfosita.

B Pulveris Digitalis . gr. j.

Pulveris SciLlsB . . . gr. j.
Pilulffl Hydrargyri . . gr. j.

Valuable in cardiac dropsy, and as a diuretic
in ascites. It is apt to salivate unless the
bowels are acting regularly.

di4

pormulm

(85) PitULA Elatbrini.

B Pulveris Elaterini Compositi gr. ij.
Extraoti Hyosoyami . • g^- 1

^ gr. Elaterini in each pill,
drastic pill for ascites.

Diuretic and

(86) PiLULA Ferri Alkalina
(Blaud).

B Ferri Sulphatis . . • 3 J-

Potassii Carbonatis . • 3J-

Pulveris Tragacanthsa. . gr. xij.

Glycerini .... n\x.

BCisoe bene ; flant pilulie, xxiv. Should be
freshly prepared. Two a day, increased to
eight, after meals.

(87) PiLUi*A Ferri Comp.

B Ferri Sulph.

Zinci Valerian . aa gr. j.

Ext. Aloes Barbadensis

Ext. Nucis Vomicffi . . aa gr. J

For the amenorrhcea and ansemia of hys-
terical girls.

(95) PuLvis AlteuativUs.

B Hydrargyri com Greta . gr. j.
Pulveris Cinnamoni Com-
positi . . • gi*- j-
Pulveris Rhei • S''- U*
Magnesii Carbonatis . . gr. ij.

Dose for a child one or two years dd.

(96) PULVIS GUAIAOI COMPOSITA.

B Pulveris Guaiaci Resinse
Sulphuris Precipitati .
Magnesii Carbonatis . aa gr.

^i. to 3ili. every evening. A valuable alter-
ative for gout and rheumatism ; and for
sciatica (gr. xx., td.).

(97) PuLVis MntABius.

B Bismuth. Carbonatas
Sodii Bicarbonatis
Pulv. Rhei
Pulv. Nucis Vomioso
Pulv. Cinnamon. Co.

To be taken befwe meals

gr. V.
gr. V.

gr. j.

gr. 1
gr. 11

For dyspepsia.

(88) PiLULA COLCHIGINJE.

B Colchicinse . . . • g^' if^r

Ext. Nuc. Vom. . . • gr* i

Ext. Hyoscyami . • gi^- 1

Ext. Gentianse . • gr- j*

Twice or thrice a day for acute gout.

(89) PiLULA Hydrargyri Ck)MPOsiTA.

B PilulfiB Hydrargyri . . gr. j.
Pulveris Ipecacuanhse . gr. \
Piluls Rhei Composite . gr. ij.

ICay be given every night to reduce arterial
tension.

(90) PiLULA PODOPHYLLI CoMPOSlTA.

B Rcsinsd Podophylli . . gr. j.

Pulveris Ipecacuanhie . . gr. j.

Hydrargyri Subohloridi . gr. j.

Extraoti Hyoscyami . . gr. ij.

A useful liver pill in hepatic congestion.

(91) PiLULA Aloini C Ferro.

B Aloini

Ext. CascarsB
Ferri Sulph. Exsic.
Ext. Bsllad. Vir.
Ext. Nucis Vom.
Ext. Hyoscyami .

gr. J-
gr. ij-
gr. j.
gr-i
gr. i

gr- J-

To make one pill or tabloid (coat with
chocolate).

(98) pulvis soammonn cum
Hydrarqyro.

B Pulveris Scammonii .
Hydrargyri Subchloridi
Pulveris Zingiberis

gr. iij.
gr. j.
gr. ij-

Dose for a child two years (rfd. An apoient
powder for thread-worms.

(99) Asthma Powder,*

R Pulv. Lobelise Inflate .
Pulv. Stramonii .
Pulv. Hyoscyami Exot.
Pulv. Folisd Belladonn»
Pulv. Cortiois CasoariUs
Black Tea .
Pulv. Potassii Nitratis aa viij.

Break up and mix th(«t>nghly all the ia-
eredients excepting tiie potassium nitrate.
Dissolve the potassium nitrate In as small a
quantity of water as poesiMe, mix it thor^
oughly with the broken leaves, and dry the
whole thOToughly. Bfay be inhaled wbSkt
smouldering, smoked in a pipe, or made «p
into cigarettes.

(100) Tabloids.

One of the chief objections to medlcbies in
the form of tabloids appears to be their In-
solubility, and the possibility of their not
passing Into the stomach unUi some ooosider-
able time after they are swallowed. Dr.
J. 8. Bristowe (** Clinical Lectures and Esssys

^ Formula kindly supfdied by Dr.
James Ross, liverpooL

FORMULM

015

on Diseases of the Neryoos System ") narrates
a case in which smali tabloids containing
morphia were found in the folds of the oeso-
phagus after death, and I have met with
similar cases. A draoffht of water or some
food should always follow their administra-
tion.

(101) Ungubntum Galam. cum
Oleo.

B CalaminiB ....

Zinci Oxidi . . . aa gr z.

Oleilini .... 388.
Adops Bonz. . • Ij.

A soothing ointment. Useful for pruritus.

(102) Ungubntum Crbolini Comp.

B Grcolin . . . . 3i-

Unguenti Hyd. Ammon. . 3"j*

Sapo Mollis . 'Si*

Pet. Mollis . . ad §j.

For psoriasis or chronic eczema (in certain
stages).

(103) Ungubntum Metallorum.

B Unguenti Hydrargyri .
Unguenti Plumbi Carbonatis
Unguenti Zinci Benzoati . aa 3iv.

For irritable or acute eczema.

(104) Ungubntum Pbtrolati
Comp.

B Hydrargyri Ammoniati . gr. x.
Ldquoris Carbonis Detor-

gentis .... 3^'

Parafiini Mollis . • Sj*

A mild tar and mercury ointment, useful
in many skin diseases.

(105) Ungubntum Salicylici bt
Cabbougi.

B Ac. Salicylici .
Ac. Carbolici .
Vaaolin .

aa gr. xxx.
adjj.

Stimulating ointment for chronic skin
affections.

(106) Ungubntum Sulphuris Co.

B Sulph. Sablimat. . gr. xxx.

Acid. Carbol. . ll^viij.

Sapo Mollis • 3^>

Adipis Benz. . ad ^j*

For acne. Should be rubbed in night and
morning. In obstinate cases Sapo Mollis
3ii. to 3iii> and more sulphur may be added.

(110) Vaporbs (Inhalations).

Direetiong. — ^A teaspoonful to be added to
a pint of boiling water, to be inhaled for five
minutes every night and morning from a
narrow-neoked Jug or suitable iimaler. In
this way use Tr. Benzoini Go. as an expectorant
and local sedative in bronctiitis and laryngitis ;
Tr. lodi as a stimulant in chronic catarrh.
Ext. Lupuli will allay irritability of mucous
membrane. 01. Eucalypti, Terebene, Creo-
sote. 01. Pini Sylvestris, may all be employed
in the same way (strength IT140 to Oi.), and
certainly produce alterative effects in cluronio
catarrh if persevered with for several weeks.

If intended for Eustaclilan medication the
following directions should be observed : About
six times in the five minutes well fill the mouth
with steam, close the nostrils with the thumb
and forefinger, shut the mouth and expire
forcibly, so as to drive the vapour towards the
ears.

(Ill) Vapor Carbonis (Anti-
Catarrhal Smelling-Salts).

B Acidi Carbolici . . • gr- xxx.

Ammonii Carbonatis . • 5J-

Carbonis Pulveris . ^J-

Olei Lavandulaa . . . Il\xx.

Tincturse Benzoini Com-

positsD . . . . §83.

A dry inhalation for catarrh. Boracic acid,
finely powdered, may be used as a snuff.

(112) Vapor Siccus.

B Olei Pini Sylvestris . • 3J-

Olei Eucalypti . . • 3J*

Tincturifi Benzoini Com-

posita) . . . • 3u*

Creosotum . . . . ad §j.

Ten or fifteen drops to be placed on the

rops
tali

sponge of an oro-nasal inhaler previous to use.

(113) Nauhbim Baths.

This treatment is commenced with weak saline baths at a tempera' ure of 92° to
95^ F., consisting of 1 pound of common salt, and 1} ounces of calcium chloride to
every 10 gallons of water. These should be given every other day for a week, the
patient remaining in the bath six minutes. The strength is then gradually increased
to 3 pounds of salt and 4} ounces of calcium chloride for every 10 gallons of water.
and the patient remains in the bath for twenty minutes, with the temperature lowered
to 85*^ F. if he can bear it. In a fortnight or more effervescing baths are employed.

916 FORMULjB

In every 10 gallons of water dissolve 2 ounces of sod. bioarb., and add 3 ounces of
hydrochloric acid just before the patient enters. Gradually increase the strength to
8 ounces of sod. bicarb, and 12 ounces of ac. hydrochlor.

It is simpler to employ *' Sandow*s Tablets " and powders, which contain the in-
C^redients for the baths specially prepared in a convenient form for ready use.

Treatment extends over five weeks. The effervescing baths are ordered according
to the discretion of the physician, and in severe cases it is sometimes unsafe to emploj
them at all.

(114) RSSISTAHCB EXEBOISSS.

(Referred to in the Treatment of Heart Disease, {51.)

These exercises, as practised at Nauheim, Hesse-Nassau, Germany, comprise a
series of movements, each, as it is performed, bsing gently resisted by the nurse or
operator. They are never to be repeated twice in succession. The patient, while
performing them, should be carefully observed, and if any ssrmptom of interfereocti
with the circulation or respiration (e,g., breathlessness, change of tint about the lips
or cheeks, dilatation of nostrils, contraction of comers of mouth, moisture on the
forehead, jrawning) appears, the movement must be at once stopped and a rest taken.
During the movements the patient should breathe regularly, ard it may be advisable
that he should count in whispers, so as to achieve this end. The attire should be
perfectly free.

The resistance is accomplished by the operator placing the palmar surface of his
hand on the aspect of the patient's limb towards which the movement is directed, or.
in the case of body movements, on that aspect towards which the movement is being
carried out. While undeigoing the course of exercises, the diet must be liberal, but
little importance is attached to the nature of the food, so long as it is plain and nutri-
tious. The movements must always be followed by a period of rest.

The movements must always be begun very cautiously — t.e., the simpler ones first
— and with every care to avoid even the appearance of foitigue. Each exercise can
be varied considerably by the operator (1) by modifying the degree of resistance^
and (2) the speed — the slower the movement, the greater the strain.^

(a) Resistance exercises, as carried out by Dr. Schott, consist of a series of 19
movements, given in an anatomical series, from which the physician, alter studying
them carefully, can select and arrange a certain number, according to the nature
and progress of the case from day to day. All exoepting 6 to 8 and 12 and 14 can be
done with the patient in the recumbent position, though not to the fullest extent.

(1) The arms are stretched out in front of the body at the level of the shoulders
with the palms meeting each other. The arms are then carried outwards ]at«naUy in
line with each other, and thereafter are brought back to their first poeitioQ.

(2) The arm and hand are placed in the fully supinated position, h^iging down,
and the forearm is flexed upon the arm, without any movement of the latter, until
the fingers touch the shoulder ; thereafter the arm is extended to its original positioa.
This movement is carried out first with one arm and then with the other.

(3) The arms, hanging down, are supinated and raised outwards until the thumbs
meet over the head, after which they are brought back to their original position.

(4) The fingers of the hands, flexed at the first phalangeal joints, are pressed
together in front of the lowest part of the body, and the arms are raised until the
ha^ds are above the head, after which they are brought back to their original positaon.

(5) The arms, hanging in the position of *' attention," are raised forwards parallel
to each other until they are elevated to a vertical position, and are then brou^t back
to the position from which they started.

(6) The body is bent forwards and then brought back to the erect position, the
knees not being moved. (Inquiry should be made of the patient for any scnsatioii
in the head, and, if such is present, the exercise must be stopped).

^ A number of nurses of both sexes have now been trained by Dr. J. Fletcher Little
to carry out this treatment in England, and also to administer the baths, the ingr&>
dients of which can be obtained from Buchner, 149, Houndsditch, KG.

FORMULJB 917

(7) The body is rotated without any movement of its feet, first to one side, then
to the other, and finally baok to its original position.

(8) The body is bent laterally as far as possible, first to one side, then to the other,
and afterwards restored to its original ereot posture.

(9) This is a movement preoisely similar to No. (1), except that it is carried out
with the fists clenched.

(10) The arms are moved in the same way as in exercise No. (2), but the fists are
firmly denohed.

(11) The arms, starting from the position of " attention,** describe a oirde by
moving forwards and upwards until they are raised vertically. Each palm is then
turned outwards, and the arms descend backwards to their original position.

(12) The arms, starting from the position of " attention,** are moved upwards and
stretched backwards as far as can be done without bending the trunk, and are then
brought back to their original position. (For this movement the patient should bo
facing a looking-glass for the attendant to watch his face.)

(13) The patient, standing with the feet side by side, and supporting himself by
leaning with one hand upon any object, flexes the opposite thigh as far as it is possible,
and afterwards extends it until the feet are again side by side. Thereafter, leaning
upon the other hand, he carries out a similar movement with the other thigh.

(14) The patient, leaning as in the last exercise, first bends the whole lower ex-
tremity of one side, kept extended, as far forwards as possible, then backwards as far
as he can, and afterwards brings it beside the other. A similar movement there-
after is carried out with the other leg.

(15) Supported by leaning both hands in front on the back of a chair, the patient
flexes first one leg and then the other upon the thigh as far as he can.

. (16) Resting on one hand, the patient raises the extended opposite lower ex-
tremity outwards as far as possible, and then brings it beside its fellow. A similar
movement is then carried out with the other limb.

(17) The arms, held horizontally outwards, are rotated forwards and backwards
at the shoulder- joint, the operator clasping the patient's wrists and resisting.

(18) The hands, held in the extended position, are first bent backwards and then
forwards as far as possible, after which they are brought back to their original position.

(19) The feet, held in their ordinary position, are first bent downwards and then
upwards as far as possible, after which they are brought back to their original position.

(6) Resistance exercises, as given in Nauheim by Dr. Gro'edel. and arranged by
him in progressive order, beginning with the simplest and least tiring movements.
Groitp I. — 1. Flexion and extension of the fingers.

2. Flexion and extension of the hand.

3. Flexion and extension of the feet.

4. Flexion and extension of the elbow.

Geoup II. — 1. Pronation and supination of the arm, with the arm fully ex-
tended.

2. Abduction and adduction of the arms (to shoulder ^evel only).

3. Flexion and extension of the knees.

4. Arms raised in front of the body and returned (to shoulder level

only).
Group III. — 1. Arms, held horizontally, are brought forwards and backwards.

2. The lower extremities, fully extended, are turned outwards and

inwards (sitting).

3. Complete abduction and adduction of the arms (the hands meet-

ing above the head).

4. Abduction and adduction of the legs (sitting).

Group IV. — 1. Arms extended, raised in front of body and up above head, then

returned.

2. Flexion and extension of hip. with flexed knee (sitting or lying).

3. Arm hanging at side of body is moved backwards and forwards

like the pendulum of a dock.

4. Flexion and extension of the trunk.

91^ FORMULJB

Group V.— 1. Arms extended and fists clenched ; arms raised in front of boily

to shoulder level, and brought back.

2. Flexion and extension of thigh, patient standing, and supporting

himself on a chair with opposite hand.

3. Flexion and extension of the head.

4. Rotation of the trunk.

Gboup VI. — 1. Flexion and extension of the hip, with extending knee (sitting

or lying).

2. Rotation of the head.

3. Trunk bent sideways and bock.

4. Abduction and adduction of the extended lower extremities,

patient standing and supported by a chair.
Gkoui' VII. — I. Sawing — the arm, being held as in the act of sawing, is moved

forwards and backwards and returned to original position.

2. The lower extremities moved forwards and backwards like the

pendulum of a clock (patient standing).

3. Raising of the trunk (l3ring down).

4. Flexion and extension of the hip (lying down).

INDEX

The principal reference to each subject is in black type.

Abadib*s sign. 212

Abdomen, abscess in, rupture of, 240

— " boat-shaped," 268

— encysted fluid in, 261

— fsDoal masses in, 263

— fluid in the, 257

— gas in the, 266

— general enlargement of, 255

— inspection of, 236

— mensuration of, 236

— pain in, causes of, 238, 244
chronic, 246

investigation of, 247

— palpation of, 236

— paracentesis of the, 260, 896

— percussion of, 236, 267

— physical examination of, 235

— recession of, 268

— regions of, 233

— symptomatology of, 233

— tumours of, 264

— tympanites of, 266
Abdominal aorta, aneurysm of, 267
pulsatile, 267

— cyst, rupture of, 240

— organ, rupture of, 240

— pain, chronic, 246
with collapse, 238

— veins, dilatation of, 259
Abscess, intracranial, 774

— of liver, 366

— of lung, 177

— perinephric, 433

— of prostate, 417

— subphrenic, 367
Acanthosis, 642

— nigricans, 681
Acarus soabiei, 664
Acetonuria. 808
Acholuric jaundice, 842
Achondroplasia, 26, 687
Achromatopsia, 867
Acid dyspepsia, 290

— eructations, 276

— pyuria, 419
Aone keloid. 683

— rosacea, 648

Acne, varieties of, 651

— vulgaris. 651
Acromegaly, 636
AcroparaE»thesia, 862
Acroteric scleroderma, 607
Actinomycosis of the liver, 357

— of lung. 177

— of skin, 677

— organism of, 902

Acute anterior poliomyelitis, 847

— BrighVs disease, 403

— diarrhoea, 316

— diseases, physiognomy in, 16

— glossitis, 226

— intestinal obstruction, 244, 333

— meningitis, 772

— nephritis, 403
— • pancreatitis, 264

— pericarditis, 61

— peritonitis, 241

— pulmonaiy cedema, 140

— suffocative catarrh, 138

— transverse myelitis, 793

— yellow atrophy, 367
Addisonian ansemia, 662
Addison's disease, 697
Adenoids, 181
Adenoma sebaceum, 667
Adherent pericardium, 55

— pleura, 171
Adiposis dolorosa, 26
Adrenalitis, 244
Adrenals, tumours of, 266
iEgophony, 131

— in pleural effusion, 141
iflrophagy, 276
iSstivo-autunmal fever, 619
Agglutination test, Widal's. 906
Agraphia, 749

Ague, 516
Amhum, 683
Air-borne diseases, 640
Albinism, 688
Albuminuria, cardiac, 74

— causes of, 402

— chronic. 404

— cyclical, 418

919

920

INDEX

Albnminaria, fanotional, 412

— in pregnancy, 412

— physiological, 412

— teste for, 385

— treatment of, 413
Albumosuria, 392

— myelopathic. 638
Alcaptonuria, 393
Alcoholic cirrhosis, 362

— injections for neuralgia, 856
Alcoholism. 730

— acute, 730

— insanity in,' 761

— tremor in, 832

Alimentary canal, perforation of, 340
Allooheiria. 720
Alopecia, causes of, 688

— areata. 688
Amaurosis, 867
Amblyopia, 867

— hysterical, 868

— mononuclear, 868

— reflex. 868

— tobacco. 867

— toxic, 868
Amenorrhosa, 447
Amnesia, 752

Amoeba of dysentery, the, 904
Amoebic dysentery, 319
Amphoric breathing, 130
Amyloid disease of the kidney, 409

of the liver, 366

of the intestines, 326

of the spleen, 374

Amyotonia congenita, 853
Amyotrophic lateral sclerosis, 803, 860
Amyotrophy, arthritic, 858

— olassincation of, 847
Anacrotic pulse. 105
Anaemia, Addisonian, 662

— aplastic, 663

— causes of, 668

— congenital, 587

— in alimentary disorders, 575

— in children, 586

— in chronic renal disease, 576

— in cirrhosis of the liver. 576

— in malignant disease, 675
• — in tuberculosis. 676

— pernicious, 662

— post-febrile, 677

— post-hffimorrhagic, 576

— secondary. 576

— splenic. 581

— traumatic. 576

— tropical diseases in. 583
Anaphylaxis, 685* 645
Anseethesia, 861

— dolorosa. 861

— localised. 861
Analgesia, Head*s areas of,' 792
Anasarca. 31

Aneurysm of abdominal aorta, 267
' — of thoracic aorta, 90

Angina cruris, 608

— Ludovici, 187

— pectoris, 61

— vaso-motoria, 61

— Vincent's. 184
Angiokeratoma, 681
Angioneurotic oddema, M5
Anidrosis. 686

Aniline derivatives, poisoning. 39. 67
Ankylostomiasis. 68S
Anl^lostomum duodenalc. 313
Anorexia, 277

— nervosa, 277
Anosmia. 864

Anterior fossa, signs of lesions of, 784

— poliomyelitis, acut^. 847
Anthracaemia. 492
Anthrax. 492

— bacillus in the blood, 905
Antivenene, 638
Antrum, empyema of, 205
Anuria, 427

Aorta, aneurysm of abdominal. 267
of thoracic, 90

— dilatation of, 94

— pulsating. 267

— rigid. 94

Aortic regrui^tation, 77

— stenosis, 76
Aphasia, 749
Aphemia, 749
Aphonia, hysterical. 196

— in mediastinal tumour. 96
Aphthous stomatitis, 220
Aplastic ansemia, 563
Apoplexy. 740
Appendicitis, 247
Appetite, excessive. 277

— perverted, 277

— loss of. 277
Arcus senilis, 19

Areas of analgesia. Head's, 792
Argyll-Robertoon pupil. 870
Arms, paralysis of the. 803
Arrhythmia, 104
Arterial blood-pressure, 105

high, 105

low, 107

— disease, 110

functional, 117

physical signs of, 110

symptoms of. 110

— hypermyotrophy. 116

— sclerosis. 112
Arthritic amyotrophy. 863
Arthritis, 609

— acute gonorrhoeal. 617
septic. 617

— chronic gonorrhoeal. 625
septic. 627

— hysterical, 627

— neuro-trophic. 628

— rheumatoid, 621

— ByphiUtic,'.627

INDEX

921

Arthritis, taberonlouB, 627
Arthropathy, in tabes, 628

— neural, 628

Artificial feeding of infants, 304
Asoaris Inmbriooides, 313
Ascites. 257

— chylous, 260

— in mitral regurgitation, 259

— paracentesis in, 260, 896
Aspei|;ilIosis of lung, 177
Aspiration. See Paracentesis

— pneumonia, 149
Astereognosis, 720
Asthenia, causes of. 693
Asthenopia. 866

— retinal, 868
Asthma. 151
Astigmatism. 866

Ataxic paraplegia, 795, 823
Ataxy, 816

— hereditary. 828
Atelectasis of long, 172
Atheroma, sjrmptoms of. Ill
Athetosis, 714, 887

Atony of stomach, 298

Atopognosis, 720

Atrophic spinal paralysis. 849

Atrophoderma, 826

\trophy, classification of muscular. 847

— of skin, causes of, 681

— of spleen. 377

— of tongue. 226
Lttitude in disease. 23
Luditoiy nerve, anatomy of. 887
XLTfB of fits. 840

urionlar fibrillation, 82
uscultation of heart, 44

— of Inngs, 129
usculto-peroussion, 96, 131. 280

ibinski's reflex, 717
kcilluria, 397, 420
kcillus ooli communis, 905

of anthrax in blood, 905
f diphtheria. 903

: f influenza, 902

-f Pfeiffer, 902

of tuberonlosis. 901. 904
of typhoid, 904
3kaohe, causes of, 458
jteriolog^oal examination of pus, 903

— of oerebro-spinal fluid, 901

— of pleural effusions, 903

— of sputum, 901

— of stools, 904

— of syphilis, 906

— of the blood, 905

— of urine, 904
l^riology, clinical, 900
ness. 688

\,Va disease, 581
3w's disease. 586
dow's disease. 211
I. alkaline. 903

Bath, creosote vapour, 176

— hot air, 908

— mercurial vapour. 908

— shower. 908

Baths, hot air. in high blood-pressure. 1 15

— Nauheim. 86. 915

— Turkish, in chronic rheumatism, 621
Bazin's disease, 676

Bedsores, 650
Beef-tea, 303
Bell sound, 131, 150
Bell's paralysis, 883. 885
Benedikt*s syndrome, 783
Beri-beri, 798
Bile-ducts, stricture of, 355
Bilharziasis. 418. 583

— the parasite of, 313, 554
Biliarv cirrhosis. 364

— colic. 351
Bilious attack. 285
Birth palsy, 796
Bismuth meal, 280
Blackhead, 651
Black tongue, 223
Blackwater fever. 519
Bladder, hsdmorrhage from. 413
Blastomycosis of lungs. 177

— of skin, 677
Bleeding in apoplexy, 744

— in Bright 's disease. 409

— in cardiac disease, 87
Blepharospasm. 865

Blood, bacteriological examination of the,
905

— chemical properties of, 556

— coagulability of, 557

— colour-index of, 547

— counts, 547

— dust, 653

— examination of, 546

— films, 549

— freezing-point of. 558

— in the stools. 327

— microscopical examination of. 549

— parasites in, 553

— platelets. 553

— pressure, 99

high, 105

low, 107

— specific gravity of. 556

— spectroscopic examination of, 557

— staining methods for, 550
Boil. 672

Bone diseases, 632
Bones, tumours of, 636
Bothriooephalus latus, 312. 314, 584
Bougie, oesophageal. 226
Boulimia, 277
Brachial neuritis. 858

— plexus paralysis. 811
Brachiplegia. 803
Bradycardia, 102

Brain, landmarks of the. 694. 894
Breath, offensive, causes of, 176, 217

022

INDEX

Breath sounds, varieties of, 129

— the, 217
Breathlesfloess, causes of, 28

— in long disease, 120

— paroi^smal, 80, 120
Bright^s disease, aoute, 403
ohronio, 406

com plications of, 381, 407

diet in, 303

hydrothorax in, 381

ocular changes in, 380

retinal changes in, 878, 879

subacute, 406

Bromide rash, 647, 672
Bromidrosis, 686
Bronchial asthma, 141

— breathing, 130
Bronchiectasis, 176
Bronchitis, acute. 135

— chronic, 154

— plastic, 166
Bronchocele, 213
Broncho-pneumonia, 148
Bronchorrhoea, 153
Bronzed diabetes, 364, 598
Brown-S^quard paralysis, 861
Bruit de diable, 564

Bruits, hsemic, 75, 564

— See Murmurs
Buhl's disease, 342
Bulbar paralysis, 815, 898

asthenic. See Myasthenia Gravis

pseudo, 894

Bullous eruptions, 661

Caisson disease, 801

Calculus pyelitis, 419

Calmette s ophthalmic reaction, 169

Cammidge's reaction, 255

Cancer a cause of pallor, 575

— general symptoms of, 588

— of the intestine, 266, 828, 336

— of the kidney, 433

— of the laiynx, 194

— of the liver, 368

— of the lung, 171

— of the mediastinum, 96

— of the oesophagus, 229

— of the pancreas, 255

— of the peritoneum, 261

— of the pharynx, 187

— of the skin, 676

— of the stomach, 295

— of the tongue, 224

— of the uterus, 445
Cancrum oris, 220
Canities, 689
Capillary pulsation, 108
Carbon dioxide snow, 679, 681
Carbuncle, 673

Cardiac dulness, 413

— murmurs, 48

— sounds, 44

— thrills, 42

Cardiac valves, position of, 47
Carphology, 23
Caruncle, 438
Case-taking, scheme for, 6

in diseases of women. 435

Casts in the urine, 394

Catalepsy, 762

Catarrh, acute suffocative. 138

— intestinal, 252

— post-nasal, 204
Catarrhal jaundice, 349

— stomatitis, 220
Cavernous breathing. 130

— sinus, thrombosis of the. 776
Cavity of lung. 157, 160

— signs of, 130, 160
CelluUtis, pelvic. 449
Cerebellar lesions, gait in. 824
Cerebellum, signs of lesions of. 784
Cerebral abscess, 774, 782

— circulation, 702

— compression, 740

— concussion, 740

— diplegia, 796

— embolism, 743, 779

— hiemorrhage, 740

— - thrombosis. 743, 779

— tumour. 781

— tumours, localisation of, 783
Cerebro-spinal fluid, bacteriological ex-
amination of, 900

characters of, 898

in meningitis, 900

— meningitis, 510

— rhinorrhoBa, 203
Cervical endometritis, 440

— sympathetic, paralysis of. 871
Cervix, methods of dilatation of. 437
Charbon. 492

Chaicot-Leyden crystals, 133
Charcot's disease. 628, 819
Cheiro-pompholyx, 663

Chest, inspection of, 123

— landmarks of, 40, 123

— measurements of. 124

— mensuration of, 123

— pain in, 120

— palpation of, 126

— phthisioa]. 126

— rachitic. 126

— shape of, 125
Cheyne-Stokes respiration, 81
Chicken pana^la, 304
Chicken-pox, 473
Chilblains, 650
Child-crowinff, 197

Childhood, physiognomy of disease in. 20

Chloasma, 641, 688

Chloral habit. 733

Chloroma, 579

Chlorosis, 659

Cholsmia, 342

Cholangitis, acute, 349

— ohronio, 354

INDEX

923

Cholecystitis, membranous, 355

— phlegmonous, 355
Cholelithiasis, 353
Cholera. 321

— infantum, 317

— senim-thorapy in, 538

— vibrio, the, 904
Cholesterin oiystals, 351
Chondrodystrophia foetalis. See Achon-
droplasia

Chorea, Cl^8

— electrica, 835

— ffravis. 835

— hereditary, 834

— Huntingdon's, 834

— hysterical, 836

— post-paralytic, 837

— Sydenham's, 833
Choroiditis, disseminata, 879

— syphilitic, 879
Choroid, tubercle of, 879
Choulmoogra oil, 673
Chromatopsia, 867
Chromidrosis, 686
Chromo-cystoscopy, 401
Chronic cervical catarrh, 440

— diseases, physiognomony in, 16
Chylous ascites, 620

Chyluria. 431
Circulation, cerebral, 702
Cirrhosis of biliary obstruction. 365

— of liver, 576

atrophic, 862

hypertrophic, 865

in malaria. 365

— of the lung, 170
Citrated milk, 305
dassifioation of diseases, 13
Claudication, intermittent, 608
Claw hand. 601
Cleido-cranio-dysostosis, 638
Climacteric, the, 444
Clinical bacteriology, 900

— investigation, general rules for, 2
Clonic spasm, 829

classification of causes of, 830

aonus, 716
Clubbed fingers, 601
Coag^ometer, 557
Cocaine habit, 733
Coooydynia, 456
Coeliao disease. 593
Coley's fluid, 590
Colic, 244

— biliary, 361

— diagnosis of, 245

— intestinal, 246

— renal, 245. 415
Colitis, acute ulcerative, 318

— mucous, 323
Collapee, 733

— in abdominal disorders, 238

— of lung, 172
CollapsUig poise, 109

Colles' law, 570

Colon bacillus, the, 905

Colon, congenital dilatation of, 332

Colour blindness, 867

— index, 547

— of face in disease, 18

— vision, testing for. 867
Coloured vision, 867
Coma, 788

— diabetic, 234, 426, 745

— in children, 747
" Coma-vigil," 466
Combined sclerosis, subacute, 796
toxic, 796

Comedo, 651

Comma bacillus. 904

Common sensation, 720

Complexion as a symptom of disease, 18

Compression, cerebral, 740

— of lung. 172
Concussion, cerebral, 740
Condyloma, syphilitic, 681
Congenital ansemia, 587

— oholsemia, 342

— heart disease, 70

— hypertrophic stenosis, 271

— laryngeal stridor, 192
Congestion, hypostatic, 169

— of kidney, 410

— of liver, acute, 347
chronic, 368

— of lung. 169

Conjugate deviation of the eyes and head,
876

significance of, 783

Constipation, 330
Consumption, 156
Contracted granular kidney, 406
Convulsions, 838

— classification of, 839

— hysterical, 843

— in cardiac disease, 103

— in infancy, 839, 846

— puerperal, 845

— ursBmic, 845
Co-ordination, 700

Cord, intramedullary tumours of the, 862

Corns, 681

Corpora quadrigemina, signs of lesions

of, 784
Corpus cidlosum, signs of lesions of, 784
Corrigan's pulse, 109
Cortex, signs of lesions of, 784
Coryza, 201
Cough, causes of, 118

— gander, 37, 91

— in aneurysm, 91

— in cardiac disease, 37

— paroxysmal, 119
Cracked lips, 216

— pot sound, 160
I Cramp. 827

I — occupation. 826
1 — writer's, 825

924

INDEX

Cranial nerves, inyestigation of the, 863
Craniotabes, 21
Creosote vapour bath, 176
Cretinism, 214

— faoies of, 27
Crisis, Dietrs, 246, 252

— in pneumonia, 145

— in tabes dorsalis, 819
Crossed paralysis, 783
Croup, 197

Croupous pneumonia, 144
Cms cerebri, lesions of the, 784
Crutoh palsy, 805
Cryoscopy, 391
Ciystals in the urine, 398
Cupping in anuria, 428
Curschmann's spirals. 133
Cyanosis, causes of, 37

— enterogenous, 38
Cyclic albuminuria, 412
Cyclical vomiting, 272
C^oloplegia, 872
C^rrtometer, 126

Cyst in abdomen, rupture of, 240

— ovarian, 261

— pancreatic, 254

— sebaceous, 675
Cystic kidneys, 434
Cystitis, acute. 417

— chronic, 418
Cystooele, 454
Cyto-diagnosis, 900

Darier^s disease, 656

Dead hands, 608

Deafness, 889

Death, sudden, causes of, 39

Debility. 593

Decubitus in disease, 221

Deep reflexes, 715

— sensibility, 699
DefsBcation, painful, in women. 456
Degeneration, reaction of, 719
Deglutition pneumonia. See Aspiration

Pneumonia
Delirium, 468

— cordis, 68

— post-febrile, 464

— reflex, 464

— tremens, 464, 781
Delusional insanity, 759
Dementia, 756

— prffioox, 760
Dengue, 490
Dentition, 218
Deroum's disease, 26
Dermatitis, exfoliative, 660

— herpetiformis. 668

— X-ray, 650

— seborrhoeio, 658
Devergie*8 disease, 660
Deviation of nasal septum, 207
Diabetes, bronzed, 364, 598

— diet in, 302

Diabetes insipidus, 426

— mellitus, 423

— pancreatic, 256, 426

— phosphatio, 431
Diagnosis, author's method of. 9
Diaphragmatic (deurisy, 120, 234
Dii^hoea. 315

— acute, 315

— chronic. 322

— dysenteric, 324

— epidemic, 317

— infantile, 316

— lienteric, 325

— nervous, 324

— senile, 325
Diastolic murmurs, 77
fallacies in diagnoms of, 78

— shock, in aneurysm, 92
Dicrotic pulse, 108
Dietaries. 301

Diet for diabetes, 302

— Haig's, for uric-acidemia. 361

— in chronic gastritis. 302

— in dyspepsia, 302

— in fevers, 541

— in obesity, 301

— in typhoid fever. 498

— " Salisbury," 302

— Tufnell*s. 95
Digestion, chemistry of, 281
Dilatation of cervix. 437

— of colon, congenital. 332

— of heart, 67

— of intestine, 332

— of oBsophagus. 231

— of stomach, 299
DUated aorta, 79, 92
Diphtheria. 499

— antitoxin treatment of, 535

— bacillus, the. 903

— of the skin. 670

— rhinorrhoBa in. 201

— throat in, 185
Diplegia. 713

— facialis, 886

— in&mtile spastic, 796
Diploooccus intraoellularis, the. 900
Diplopia, 874

Dipsomania. See Alcoholism
Disinfection, 539
Disseminated sderosis. 832
Distoma pulmonale, 584
Distomiasis, 584 ; and see BQharna
Diver's paralysis, 801
Diverticulum of oesophagus, 231
Double facial paralysis. 886

— murmurs, fallaoies in diagnosis of, 79

— vision, 874
Dropsy, 31

— epidemic, 33
Drowsiness, 709
Drug eruptions, 647
— - habits, 732

Dry mouth, 217

INDEX

925

Dual personality, 752
Duohenne'fl paialysis, 24, 862
Dudgeon's sphymograph, 100
Duhring^s disease, 668
Duodeiukl uloer. 295
Duodenum, tumours of, 265
Dwarfism, causes of, 26
Dysentery, 319

— the amoeba of, 904
Dysmenorrhcaa, 441
Dyspareunia, 457
Dyspepsia, aoid, 290

— acute. 285

— atonic, 288

— chronic, 288

— diet in, 302

— intestinal, 252

— irritable, 290

— neurasthenic, 301
Dysphagia, 227

— causes of, 228

— in aneurysm, 93

— in mediastinal tumours, 96

— investigation of, 225

— prognosis and treatment of, 231
Dyspnoea, 28

— paroxysmal, 30

Ear, anatomy of the, 887

— discharge from the, 891

— inspection of, 887

— pain in the, 890
Eccnymosis, 641

— in scurvy, 581
Eclampsia, 845

— puerperal, 845
Ecthyma, 670
Eczema, 661

— barbae, 671

— epidemic peri-oral, 659

— erythematous, 650

— marginatum, 659, 663

— papular, 662

— seborrhoeic, 658
Egg flip. 304

Ehrlich-Biondi stain, 550
Eighth nerve. 887

Electrical examination of muscles, 717

— lymphangiectodes, 603

— telangiectodes, 602
Electro-cardiogram, 50
Elementary sMn lesions, 641
Elephantiasis Grsecorum, 676
Eleventh nerve, 892
Emaciation, 546

— causes of, 687

— ffeneral remarks on, 24
Embolism, cerebral, 743, 779

— fat, 746

— in cardiac valvular disease, 80

— in endocarditis, 56, 59

— in spleen, 246

— into arteria centralis retinae, 879

— into spinal cord, 794

Embolism of kidney, 414

— of lungs, 122

— of mesenteric artery, 244
Emphysema, 173
Emplastra, 913
Empvema, 143

— of ethmoidal sinuses, 204

— of frontal sinus, 204

— of gall-bladder, 354

— of sphenoidal sinus, 204

— of the antrum of Highmore, 205
Encephalitis, 814

E^ndomic hsematuria, 413
Endocarditis, acute, 56

— chronic, 71

— malignant, 68, 528

— murmurs of, 55

— recurrent, 56
Endocervicitis, 440
Endometritis, 440
Enema, nutrient, 909
Enlargement of the body, causes of, 25
Enteric fever, 494

Enteroptosis, 253
Entozoa. See Worms
Enuresis, nocturnal, 430
Eosinophilia, 552
Epicritic sensation, 698
Epidemic jaundice, 350

— roseola, 489

— stomatitis. 221
Epidermolysis bullosa, 669
Epigastrium, pulsation in, 235
Epilepsy in children. 768

— idiopathic, 839

— Jacksonian, 844

— masked, 736

— minor. 736

— senile, 595, 787

— treatment of, 843

— varieties of, 841
Epileptic insanity, 760. 841
Epileptiform neuralgia, 857
Epiphysitis, 633
Epiplopexy, 363
Epistaxis, 207

Epithelioma of skin, 676* 679
EpulU, 219
Equilibration, 891
Eauinia, 492

Ero's syphilitic spinal paralysis, 795
Eructations, 275
Eruptions, bullous, 661

— arug, 647

— multiform, 673

— nodular, 674

— pustular, 671

— vesicular, 661
Erysipelas, 479
Erythema, 646

— faciei. 650

— induratiun scrofulosorum, 676

— multiforme, 648

— nodosum. 649

026

INDEX

Erythema pernio, 660

— soariatinoides, 646
Erythematous eczema, 660, 662

— stomatitis, 220
EiythrsBinia, 38
Eiythrasma, 661
Erythromelalffia, 606
EiTthropsia, 867
Esbaoh's albuminometer, 386
Ethmoid sinus, empyema of, 205
Eustachian oatheterisation, 889
Ewart's sign, 52

Examination of children and infants, 8

— of patients, rules for, 5
Exanthemata, 473
Excrescences of the skin, 680
Exercises, resistance, 916

— respiratory, in emphysema, 175
Exfoliative dermatitis, 660
Exophthalmic goitre, 211

facies of, 19

Exostosis, 636

Extra-medullary tumours, 787
Extra-uterine pregnancy, 445, 452
Extremities, gangrene of, 607
Eye, examination of, 865

— strain, 865

Eyeballs, movements of, 873
Eyelids, abnormalities of, 865
Eyes, pam in, 865

— symptoms of disease referable to the.

Face, expression of, in disease, 15, 22

— hemiatrophy of, 887

— swelling of, as a symptom of disease.

Facial nerve, anatomy of, 882

— paralysis, 883

double, 886

Facies of disease, 15

Fsecal fistula in tuberculous peritonitis,
250

— masses in abdomen, 263
Fseoes, abnormal substances in, 309

— blood in, 309, 827

— examination of, 308

— microscopical appearance of, 311
Fainting, causes of, 36

Falling sickness, 839

False appetite, 277

Family periodic paralysis, 814

Farcy. See Glanders

Fat embolism, 746

Fatty heart, 88

— liver, 265
Favus, 688
Febricula, 499

Feeding, artificial, of infants, 304
-- by nasal tube. 232

— by oesophageal tube. 232

— defective, 591
Ferrier's snuflF, 202
Festination, 816

Fever, hectic, 521

— symptoms of, 459
Fevers, classification of. 472

— diet in, 541

— disinfection after, 539

— eruptive, 473

— paraplegia after, 801
Fibroid of uterus, 443

— phthisis, 168
Fibroma of oesophagus, 229
Fibrosis of lung, 168

Fifth nerve, affections of, 880

investigation of, 879

Filaria sang^uinis hominis, 313. 554
Fingers, clubbed, 601

— glossy, 601
First nerve, 863
Fissure, 641

— of anus, 322
Fissured lips, 216
Fissures oi^ tongue, 226
Fits, epileptic. 840
Flatulence, 275
Flint's murmur, 79
Floating kidney, 251

— liver, 370

— sfdeen, 376
Floccitatio, 466

Fluid in the abdomen, 257. 261
Fluids, pathological, 896
Foetal endocarditis, 71

— rhvthm, 68
Foetid bronchitis, 155
Folie circulaire. 755
FoUicular tonsiUitis, 183
Folliculitis, pustular, 671
Foods, artificial proteid, 304

— invalid, 301

— predigested, 303
Foot-and-mouth disease, 221
Foreign body in larynx, 189

in trachea, 191

Formulae. 908

Foul breath, gastric. 277

Fourth nerve, paralysis of. 873

Fragilitas ossium. 638

Framboesia. 677

Freckles. 683

Frequent micturition, 428

Friedreich's ataxy. 823

Frog-faco. 207

Frontal lobe lesions. 784

— sinus, empyema of, 204
Functional albuminuria, 412

— aphonia. 196

— hemiplegia. 781

— murmurs of heart, 73

— paraplegia, 799
Furring of tongue, 222
Funmculosis, 672

Oairdner's line, 129.371

Uait, 815

Gall-bladder, chronic catarrh of. 354

INDEX

Oall-bladder, diseaaes of the, 354

empyema of, 354

phlegmonous mllammation of, 354

— stone, impaction of, in bowel, 334

— stones, 361
GaUop rhythm, 68
Galloping consumption, 139
Galton's whistle, 887
Gander cough, 91

Gangrene in arterio-sclerosis. 114

— of extremities, 607

— of lung, 176
Gargles, 909
Gastralgia, 291
Gastric atony, 280, 298

— contents, estimation of active hydro-

chloric acid in, 283

of ferment activity of, 283

examination of, 281

— dilatation, 298

— neuralgia, 858

— neurasthenia, 301

— pain, 270

— ulcer, 274, 202

perforation of, 240

treatment of, 294

Gastritis, acute, 286

— alcoholic, 298

— chronic, 273, 288, 207

diet in, 302

Gastroptosis, 301
Gastrostaxis, 274
General debUity, 543

— paralysis, 767

— peritonitis, 241

Generalised paralysis, causes of, 812

Geographical tongue, 225

German measles, 489

Giddiness, 710

Gingivitis, 219

Glanders, 492

Glands, mediastinal, enlargement of, 96

Glandular fever, 507

G16nard's disease, 262

Glossitis, acute, 225

— chronic, 226

Glosso-labio-laryngeal palsy, 893
Glosso -pharyngeal nerve, the, 891
Glossy fingers, 601

Glottis, oedema of, 191
Glycosuria, 386, 428

— temporary, 423

— tests for, 386
Goitre, exophthalmic, 213
facies of, 19

— simple, 211, 213
Gonococcus, the, 904
Gonorrhoea, arthritis, acute, in, 617
chronic, in, 625

— . warts in, 681
Gout, acute, 609

— chronic, 619

Growers, hsemoglobinometer, 547
Gram's method of staining, 901

Graves' disease, 213

facies of, 19

Gravid uterus, displacement of, 238
Growing pains, 600
Gullet, the, 226
Gumma of heart, 62

— of liver, 365

— of skin, 675
Gums, affections of, 219
Guttse, 909

Habit spasm, 836
Hffimatemesis, 273
Hsematocele, pelvic, 452
Hsematomyelia. 794
Hsematoporphyrinuria, 391
Hsematorrhaonis, 794
Hematosalpinx, 461
Hsematuria, 390

— causes of, 413

— endemic, 413

— paro^smal, 416
-- tests for, 390
Hsemic murmurs, 660
Hsemoohromatosis, 698
Hsemooytometer, 648
Haemoglobin, estimation of, 646
Hsemoglobinometer, 547
Hsemoglobinuria, 391

— paroxysmal, 416

— symptomatic, 416
Hsemoglobinuric fever, 519
Hsemopericardium, 54
Haemophilia, 682

— arthritis in, 618
Haemoptysis, 121
Haemorrhage, cerebral, 740

— uterine, 442
Haemorrhagic pancreatitis, 244
Haemorrhoids. 328

Haig's diet, 361

Hair, diseases of, 686

Hairy tongue, 223

Harrison's sulcus, 125

Hastings Gilford's infantilism, 27

Hay fever, 202

Headache, 706

— sick, 869
Head retraction, 23

Head's areas of analgesia, 792
Hearing, testing for, 886
Heart-block, 103
Heartburn, 276
Heart, 28

— congenital disease of, 70

— differentiation of valvular diseases, 72

— dilatation of, 67

— diseases of, acute, 51

of. chronic, 63

classification of, 50

of chronfc, 64

exercises in, 916

physical examination in, 40

pulse in, 48

928

Heftrt. fatty. 88

— fibroid, 88

— fonotional murmurs of, 72, 660

— flouty, 611

— nypwirophy of, 64

— irritable, 33

— organic murmurs of, 72

— syphilis of, 62

— valvular disease, 71
Heat-stroke, 512
Heberden's nodes, 601
Hebra's prurigo, 663
Hectiofever, 521. 626
Hegar's dilators. 437
Hebmnthiasis. 312. 584
Hemiannethesia, 860
Uemianopia, 869
Hemiatrophy facialis, 887
Hemicrania, paroxysmal, 859
Hemii^egia. 777

— causes of, 777

— crossed, 784

— due to embolism, 779

to hamorrhage, 779

to injury, 778

to tliombosis, 779

to tumour, 781

— hysterical, 781

— in children, 786

— of gradual onset, 781

— of sudden onset, 778

— symptoms of, 777

— syphUitio, 779

— treatment of, 783
Henoch's purpura, 618
Hepatic colic, 245
Hepatoptosis, 370
Hereditary ataxia. 828
Hernia, 334

Herpetic stomatitis, 220
Herpes, 666
Hiccough, 276

— in peritonitis, 242
High arterial tension. 106
Hippocratic facies, 16
Hippus. 870

Hirschprung's disease, 332
Hirsuties. 689
Hodgkin's disease, 559
Hoffmann's bacillus, 903
Hospited sore throat, 180
Huntingdon's chorea. 834
Hutchison's teeth, 20
Hydatid cyst of kidney, 434

— of liver. 366

— of lung, 172

— of spleen, 376
Hydrocephalus, 894
Hydrocystoma, 667
Hydronephrosis, 432
Hydropericardium, 69
Hydrophobia. 829
Hydropneumothorax. 160
Hydrosalpinx, 461

INDEX

Hydrotherapy in typhoid fever, 498

Hydrothorax, 168

Hyperacidity, 276

HypersBBthesia, 861

Hyperagnsis, 882

Hypeia&esia, Head's areas of, 792

H^eroUorhydria, 276. 290

Hyperklrosis, 686

HyperkeratoAs, 642

Hypermetropia, 866

Hyperpieeis, 116

Hyperpyrexia, treatment of, 541

Hyper-reoonance. causes of, 174

Hypertonia, 716

Hypertrichosis, 689

Hypertrophic stenosis of pylorus. 271

Hypertrophy of heart, 64

Hypnotisnf. 764

Hypochomlilaus, 729

Hypoglossal nerve, 892

Hypostatic pneumonia, 169

Hypotonia, 715

Hysteria, 727

— annethesia in, 728

— aphonia in, |96

— oonvulsionain, 843

— hemiplegia in, 781

— insanity in, 760

— joint affection in, 627

— monoidegia in, 812

— paraplegia in, 800

— rigidity in, 826

— tremor in, 832, 836

— vomiting in. 271
Hysterical angina pectoris. 61
Hystero-epilepsy. 844
Hysterogenic areas, 728

Ichthyosis, 661
Icterus, 340

— gravis, 357

— neonatorum, 342
Icthyosislinguffl, 225
Idiocy, 765
Idioglossia, 748
Idiopathic anaemia, 562

— muscular atrophy, 861
Immunisation; remedial, 535
Immunity, 52^

Impetigo conti^osa, 665, 6^

— herpetiformis, 670
Incontinence of urine, 428

nocturbal, 430, 891

Inco-oidination, 701, 714, 815

— tests for, 714
Incubation periods, 461
Indian ink stain, 907
Indicanuria, 393
Indigestion, chronic, 287
Infantile convulsions, 839, 846

— diarrhoea, 316

— paralysis. 847

— scurvy, 586

spinal and cerebral paralysis, 796

l^DEX

92d

Infantile stridor, 192
Infants, feeding of, 304
Infections, duration of, 461
Infective jaundice, 350
Inflammation, intracranial, 709
Influenza, 503

— Pfeiffer's bacUlua of, 902
Inf ramammary neuralgia, 858
Infusion, saline, 576
Inhalations, 915
Injections for neuralgia, 850

— intramuscular, 571
Insane, removal of the. 763
Insanity, 753

— alcoholic, 761

— hysterical. 760

— moral. 761

— of adolescence, 765

— puerperal. 761

— syphilitic, 761
Insomnia, 709
Insular sclerosis, 832
Intercostal neuralgia, 858
Intermenstrual pain, 442
Intermittent claudication, 608

— pulse, 104

Internal capsule, signs of lesions of, 784
Interstitial nephritis, 407

— pneumonia, 170
Intertrigo, 650
Intestinal colic, 245

— dyspepsia, 252

— obstruction, acute, 244, 333
chronic, 249, 336

— ptosis, 253

— worms, 314, 329

treatment of, 330

Intestine, cancer of, 323

— catarrh of, 252

— dUatation of. 332, 337
Intestines, amyloid disease of, 325

— stricture of, 336

— syphilis of, 323

— idcoration of. 322
Intoxication, 745 ; and see Alcoholism
Intracranial abscess, 774

causes of, 775

— inflammation, 769

— lesions, localisation of, 783

— syphilis, 844

— tumour, hemiplegia in, 781
Intramedullary tumours of spine, 790,

862
Intramuscular injections, 571
Intussusception, acute, 334

— chronic, 337
Inunction, mercurial, 571
Invalid foods. 301
Inversion of uterus. 455
Iodide rash, 647, 672
lodophilia, 553

Iritis, 871

Irritable dyspepsia, 290

— heart, 33

Jacksonian epilepsy, 844
Jail fever, 490
Japanese river fever, 513
Jaundice, 340

— acholuric, 342

— acute catarrhal, 349

— causes of, 341

— diaffnosis of, S40, 350

— epidemic, 350

— infective, 350

— malignant, 367

— of the newborn, 342

— septic, 350

— toxsemic, 341
Jerks, 715

Joint sense, 701, 714, 721
Joints, examination of, 604
Jungle fever. See Malaria

Kahler's disease, 638
Kala-azar, 518, 591

— in infants, 376

— protozoon of, 555, 896, 905
Kaposi's disease, 685
Keloid, 682

— acne, 683
Keratodermia, 681
Keratosis follicularis, 656

— pilaris, 656
Kerion, 678, 686
Kemig's sign, 715

Kidney, amyloid disease of, 409

— congestion of, 410

— contracted granular, 406

— floating, 251

— hfiBmorrhage from, 414

— hydatid of, 434

— in cardiac disease, 410

— injury to, 416

— large white, 405

— malignant disease of, 433

— movable, 251

— pain in, 381

— stone in, 414

— tumours of, 432
Kidneys, cystic disease of, 434

— examination of, 401
KinsBsthetio sense, 701, 714, 721
Kleptomania, 761
Knee-jerk, 715

Kooh*s comma bacillus, 904

— postulates, 531
Koplik*s spots, 487
Kraurosis vulv®, 683

Lactosuria, 388
Lallmg, 748
Landmarks of chest, 40
Landouzy-D^j^rine myopathy, 852
Landry's paralysis, 799, 815
Lardaceous disease. See Amyloid
Large white kidney, 405
Laryngeal stridor, congenital, 192
Laryngismus stridulus, 197

930

INDEX

Laryngitis, acute, 190

— ohronio, 191

— stridulosa, 190, 198
Laiyngosoopy, 188
Larynx, the. 188

— benign new growths of, 193

— foreign body in, 191

— malignant growths of, 194

— pachydermia of, 193

— papilloma of. 193

— paralysis of. 195

— oedema of, 191

— synhilis of, 193

— tuberculosis of, 192

— ulceration of, 192
Latent pericarditis, 65

— ursBmia, 428
Lateral nystagmus. 876

— sclerosis, amyotrophic. 795, 808, 850
Lathyrism. 796

Lead poisoning, 573
Leishman-Donovan bodies, 556
Leishman's stain, 550
Leiter's coils, 542
Lenhartz treatment, 294
Lentigo. 683
Leontiasis ossea, 638

— satyriasis. 685
Leprosy. 676, 685

— macular, 661
Leptomeningitis, 772
Leptothrix, 690

Lesions of skin, elementary, 641
Leucin crystals, 351
Leucocytes, variations in, 651
Leucocythsemia, 577
Leucocytosis, 552
Leucoderma, 641, 688
Leucopenia, 649
Leucoplakia linguae, 224

— vulvae, 683
Leuoorrhoea, 439
Leukaemia, 677

— acute lymphatic, 629, 678

— lymphatic, 578

— nodules in, 677

— spleno-medullary, 677
Lichen acuminatus, 660

— pilaris, 666

— planus, 656
palate in, 188

— scrofulosorum, 656
Limb, oedema of one, 602
Limbs, examination of, 605

— pain in the, 699
Linctus, 910

Lineae albican tes, 235
Linimenta, 910
Lips, 20, 216

— cracked, 216
Lipuria, 431
Ldthaemia, 359

— in diseases of liver, 339
Lithuria. 359

Little's disease, 796
Ldver, abscess of, 355. 360

— actinomycosis of, 357

— acute congestion of, 347

diseases of, 347

yellow atrophy of, 357

— amyloid disease of. 366

— area of dulness of, 344

— atrophic cirrhosis of, 363

— oanoer of, 368

— chronic congestion of, 368

— cirrhosis of, 862, 581

— congestion of, in mitral regoigitatioD.

— disease, symptoms of, 339

— fatty, 365

— floating. 370

— functional derangement of, 359

— hob-nail, 362

— hydatid of, 366

— hypertrophic cirrhosis of, 365

— lingiform lobe of, 264

— painful, 339

— physical examination of, 343

— puncture, 896

— sarcoma of, 370

— syphilis of, 365

— tumours of, 264, 869
Lobar pneumonia, 145

diagnosis from broncho - pneu-
monia, 146
Lobular pneumonia, 148
Localisation of cerebral lesions, 783

— of spinal lesions, 791
Lock-jaw, 827

Locomotor ataxy, 816. See also Tabes

Lotions, 910

Low blood-pressure, 107

Lower neuron paralysis, 796

Ludwig's anffina, 187

Lumb{^, 629

Lumbar plexus paralysis, 811

— puncture, 897
Lunacy, certification of. 763
Lung, abscess of, 177

— carcinoma of, 171

— cavity of, 160

— cirrhosis of, 170

— collapse of, 172

— compression of, 172

— congestion of, 169

— consolidation of, diagnosis from fluid,

131

— fibrosis of, 170

— gangrene of, 176

— hydatid of, 172

— malignant disease of, 171

— oedema of, 169

Lungs, actinomycosis of, 177

— acute pulmonary oedema of. 140
tuberculosis of. 139, 148

— adventitious sounds in, 130

— atelectasis of, 172

— auscultation of, 129

INDEX

931

LtingB, auBonlto-peronfision of. 131

— olastomyoosis of, 177

— breathlessness in diseases of, 120

— ohronio diseases of , 153
tubercnlosis of, 167

— classifioationof ohronio diseases of, 153
of diseases of, 133

— oongestion of, in mitral regmgitation,

— embolism of, 122

— pain in diseases of, 120

— peroussion of, 127

— physical examination in diseases of,

123

— symptomatology of diseases of, 118

— syphilis of, 173

— thrombosis of, 122
Lapos erythematosus, 649

— pernio, 649

— ynlgaris, 674
Lymphadenoma, 97, 529, 679

— glands in, 604

— of mediastinal glands, 96
Lymphatic glands, enlargement of, 603
in lymphadenoma, 604

in syphilis, 604

tuberculosis of, 603

— leuksemia, 678
Lymphatism, 40
Lymphocyth»mia, 578
Lympho<^rtosis, 552
Lymphosarcoma, 680

— 01 mediastinum, 96
Lysis, 469

MaeBumey*s point, 248
Maoroglossia, 226
Macular eruptions, 6, 41, 646
Madura foot, 677
Main en griffe, 601
Malaria, 515

— cirrhosis of liver in, 365

— parasites of, 563

— pernicious, 519

— varieties of, 516
Malignant disease. See Cancer

— endocarditis, 56

— pustule, 492
Malta fever, 508

bacteriology of, 905

Mania, acute, 754
delirious, 754

— chronic, 755
Mapped tongue, 225
Marasmus in children, 591
Marginatum, eczema, 669, 663
Masaftge, abdominal, in constipation, 332
Measles, 487

— German, 489

Mediastinal glands, enlargement of, 96

— growths, 95
Mediastinitis, suppurative, 97
Mediastinum, abscess of, 97

— tumours of, 95

Mediterranean fever, 508
Medulla, lesions of, 784
Melaena, 328

— neonatorum, 328

— treatment of, 328
MelansBmia, 553
Melancholia, chronic, 765
Melanoderma, 641
Membranous croup, 499
Memory, defects of, 752
MM^re's disease, 737
Meningeal thickening, 794, 828
Meninges, diseases oi, 701
Meningitis, acute, 772

— cerebro-spinal fluid in, 900

— chronic, 782

— epidemic cerobro-spinal, 510

— posterior basic, 773

— tuberculous, 770
Menopause, 444
Menorrhagia, 442

Mental defect in childron, 765

— deficiency, 765

— disorders, 763

Mesenteric artery, embolism of, 244
Methsemoglobinsemia, 39
Methsemoglobinuria, 391
Methods in study of disease, xxiv

— of diagnosis, prognosis, and treat-

ment, 9
Metrorrhagia, 442
Microcephaly, 21, 767
Micrococcus melitensis, the, 905

— tetragenus, 902

Micturition, difficulty in, in women, 450

— increased frequency of, 429, 456

— painful, in women, 456
Miodle fossa, lesions of, 784
Migraine, 859

MiUaria, 667
Milium, 656
Milk, citrated. 305

— peptonised, 303

" Milk spot " murmur, 76
Millard-Giibler S3nidrome, 783
Mitral regurgitation, 73
pulmonary congestion in, 74

— stenosis, 77
Mittelschmerz, 442
Mixtures, 911
Moebius*s sign, 865
Moles, 684
MoUities ossium, 638
Molluscum oontagiosum, 676

— fibrosum, 676
Mongolian imbecility, 766
Mongolism, 26
Monoplegia, 803

— cerebral, 812

— hysterical, 812

— spinal, 812
Moral insanity, 761
Morbus cceliacus, 593
Moro's test, 159

932

INDEX

Morphinism, 529, 782
Morphino-mania. See Morphinism
Morphoea, 682, 685
Motor disorders, 777

— tract, 695
Mouth, the, 216

— breathmg, 208
Multiform eruptions. 673
Multiple myeloma, 638

— peripheral neuritis, 797
Mumps, 506

Murmur, Austin Flint's, 79
Murmurs, cardiac, diagram of, 45

— cardio-respiratoiy, 76

— diagnosis of endo- and pericardial, 55

— diastolic, of heart, 77

— double, 79

— functional, of heart, 72

— hsemic, 560

— " milk-spot," 76

— of heart, diagnosis of, 73

— organic, of heart, 72

— systolic, of heart, 73
Muscle sense, tests for, 714

Muscles, electrical examination of, 714

— examination of, 604

— tumours of, 630
Muscular atrophy, 847, 850
peroneal type of, 852

— djrstrophy, 851

— rheumatism, 628

— twitchings, 837
idiopathic, 851

progressive, of Hofihnan, 850

Musculo-spiral paralysis, 808
Myasthenia gastrica, 299

— gravis, 813
Myasthenic reaction, 813
Mycosis fungoides, 677
Mydriasis, 872

Myelitis, acute difihise, 794
transverse, 793

— chronic transverse, 794
Myelocytes, 552
Myelopathic albumosuria, 638
Myiasis. 202 329.
Myocardial degeneration, 88
Myoclonus multiplex, 835
Myopathy, 851

— Erb's juvenile, 851

— faoio-scapulo-humeral type of, 851

— pseudo-hypertrophic, 24, 862
Myopia. 868

Myosis. 871
Myositis. 631

— ossificans, 631
Myotatic irritabUity, 716

Myotonia, congenital. See Thomsen's

JDisease
Myxoedema. 596

— facies of, 18

Nasal discharge, 200, 202

— feeding. 232

Nasal obstruction. 206
causes of, 203

— polypus. 208

— spur, 207
Nauheim baths, 86. 915

— exercises, 86, 916
Nausea, causes of, 270
Nebuls, 913

Neisser's method of staining, 903
Nephritis, acute, 403

— chronic, 404

— delirium in, 382

— interstitial, 406

— parenchymatous, 405

— tubal. 405
Nephroptosis, 252

Nerves, functions of spinal, 788

— paralysis of individual, 804
Nervous diseases, 693
examination in, 711

— faints, 36

— system, anatomy of, 692
Nervousness, 706, 723
Nettle-rash. See Urticaria
Neuralgia, 853

— epileptiform, 857

— facial, 856

— gastric, 858

— inframammary, 858

— in neck, 858

— intercostal, 858

— lumbar, 859

— mammary, 858

— sciatic ,857

— spinal, 859

— trifacial or trigeminal. 856

— visceral, 246
Neurasthenia, 723

— asthenopia in, 868

— dyspepsia in, 301

— in movable kidney, 252

— in visceroptosis, 253

— parsesthesia in, 862
Neuritis, alcoholic, 797
~ brachial, 811. 858

— multiple peripheral, 797

— of single nerves, 804

— optic, 878
Neuro-palpitation. 59
Neuroses, occupation, 825
Night blindness, 869
Nmth nerve, 891
Nocturnal enuresis, 430
Nodular eruptions. 674
Nodules, rheumatic, 675
Noma oris, 220

— vulvffl, 438
Nose bleeding, 207

— examination of, 199

— polypi of, 206

— tuberoulosis of, 204
Notification of infectious diseases, 539
Nutrient enemata, 909
Nystagmus, 876

INDEX

933

Obesity, 25

— diet in, 302

— treatment of, 25
Obsessional insanity, 761
Obstetrical paralysis, 811
Obstruotion, acute intestinal, 333

— chronic intestinal, 336

— portal, 258

— pyloric, 271. 300
Obturator hernia, 246

Occipital lobe, signs of lesions of, 784
Occupation neuroses, 825
Ochronosis, 685
Ocular paralysis, 875
Oculo-motor defects, 875
CEdema, causes of. 33

— glottidis, 191

— hereditary. 33

— in cardiac disease, 82, 74, 259

— in hepatic disease, 32, 259. 846

— in mediastinal tumours, 96

— in mitral regurgitation, 74

— efface, 17

— of lung, acute, 140
chronic, 169

— of one limb, 602

— of tongue, 225

— renal, 32, 269, 879
Oertel treatment, 86
(Esophageal bougie. 232

— tube, feeding by, 232
CEsophagitis, acute, 230
CEsophagus, cancer of, 229

— dilatation of, 231

— diverticulum of, 231

— examination of, 227

— fibroma of, 229

— foreign bodies in, 230

— myoma of, 229

— paralysis of, 230

— rupture of, 31

— spasm of, 230

— stricture of, 229

— tumours pressing upon, 228

— ulcer of, 230
Ointments, 915
Olfactory nerves, 863
Open-air treatment, 165
Ophthalmic reaction of Calmettc, 159
Ophthalmoplegia externa. 876

— interna, 871
Ophthalmoscopy, 877
Opisthotonos. 22

Opium poisoning. 529, 746
Oppenheim's disease. See Amyotonia

Congenita
Opsonic index, 534
Optic atrophy, 868, 878

— disc, 878

— neuritis, 878

— thalamus, signs of lesions of, 784
Organisms, examination for, 901
Orientation, 891

Orthopnoea, 28

Osteitis, chronic, 636

— deformans, 638
Osteo-arthritis, varieties of, 623
Osteo-arthropathy, pulmonary, 638
Osteogenesis imperfecta. 638
Osteomalacia, 638

Osteomyelitis, acute infective, 523, 682
Otalgia, 890

Otorrhoea, 890, 891
Otosclerosis, 890
Ovarian cyst, 261

ruptured, 240

Ovaritis, 451
Oxaluria. 394, 400. 481
Oxyuris vermicularis, 312, 329
Ozasna. 204

Pachydermia laryngis, 193
Pachymeningitis, 782

— cervical, 795, 828

— hemorrhagica, 741

— spinal, 794, 828

Paget's disease of the nipple, 663
_ — See Osteitis Deformans
Pain after food, 270

— causes of abdominal, 238

— in aneurysm, 91

— in chest, causes of. 34, 120

— in liver disease, 339, 367

— in lung disease, 120

— in the back, 457

— in the limbs, 599

— intermenstrual, 442

— investigation of abdominal, 239

— prsecoidial, 34
Painful coitus, 457

— defecation, 456

— menstruation, 441

— sitting. 456
Palate, the, 217

— paralysis of, 893
Pallor of the skin, 544
Palpitation, causes of. 33
Pancreas, calculus of, 246

— cancer of, 255

— cysts of, 254

— diseases of, 264

— haemorrhage into, 244
Pancreatic diabetes, 255
Pancreatitis, acute, 254

— chronic. 255

Papillitis. 878. See Optic Neuritis
Papilloma of larynx, 193

— Imeare, 661, 681
Pappataci fever. 513
Papular eruptions, 661, 655

— syphilide, 655
Papule, definition of, 641
Paracentesis abdominis, 260, 896

— in hydrothorax, 169

— of abdomen, 260, 896

— pericardii, 64, 896

— thoracis, indications for, 142
in pneumothorax, 151

934

INDEX

Paracentesis thoracis, method of, 142
Paracusis WUlisu, 887
Panesthesia, 862
Paraffusis. 882
Parakeratosis, 642
Paralysis. See Paraplegia

— agitans, 831
attitude in, 23

— BeU's, 883, 885

— Brown-S^uard, 861

— bulbar, 893

— causes of generalised, 812

— diver's, 801

— Duchenne*s, 852

— facial, 883

— family periodic, 814

— forms 01 ffeneralised, 812

— functions, 785, 799

— hemiplegic, 777

— infantae, 847
cerebral, 796

— lAndouzy-D^j^rine, 852

— Landry's, 799, 816

— lower motor neuron type of, 796

— musculo-spiral. 808

— obstetrical, 811

— of both arms, 803

— of oervical ^rmpathetic, 871

— of larynx, 195
in aneurysm, 91

in mediastinal growth, 96

— of oesophagus, 230

— of one limb, 803

— of one nerve, 804 c/ seq.

— plexus, 811

— pseudo-hypertrophic, 24, 862

— rigidity with, 825

— toxic combined, 796

— upper motor neuron type of, 786
Parametritis, 449
Paramyoclonus multiplex, 835
Paranoia, 760

Paraplegia, 785

— after fevers, 801

— ataxic, 795, 823

— compression, 786

— Erb^s, 795

— flaccid, 796

— functional, 799

— hysterical, 800

— prognosis of, 801

— reflex, 801

— spastic, 786, 795

— treatment of, 801

— variable, 799

— varieties of, 785
Parasites in blood. 553, 905

— intestinal, 311

— of malaria, 553
Parasyphilitic diseases, 566
Parenchymatous nephritis, chronic, 405
Parkinson's disease, 23, 881
Parosmia, 864

Parotitis, epidemic, 506

Paroxysmal dyspnoea, causes of, 30

— hsemog^obinuria, 416

— tachycardia, 59
Pastes, 913

Pathologioal fluids, characters of, 898

examination of, 898

methods of obtaining, 896

Pediculosis, 689
Poliosis rheumatica, 618
Pellagpnk, 651
Pelvic cellulitis, 449

— hsematocele, 462

— pain, 448

— peritonitis, 448

— tumours, 454
Pemphigus, 668
Penash. See Myiasis
Peptonised beef-tea, 303

— milk, 303
Peptonuria, 392

Percussion in cardiac disease, 127
Perforation of alimentary canal, 240

— of cyst, 240
Pericamitis, acute, 51

— latent, 55

— murmurs of, 65

— paracentesis in, 64, 896
Pericardium, adherent, 55

— diseases of the heart and, 28
Perichondritis, 192
Perihepatitis. 355
Perimeter, 867
Perimetritis, 448
Perinephric abscess, 433
Periodic paralysis, family, 814
Peri-oral eczema, 663
Periostitis, acute, 633

— chronic, 636

— syphilitic, 636
Peripheral neuritis. 797
Peritoneum, cancer of, 251

— fluid in, 257

— gas in, 256
Peritonitis, acute, 214

— chronic, 251

— pelvic, 448

— tuberculous, 250
PeritonsUlitis, 183
Pernicious antemia. 562
Peroneal muscular atrophy, 852
Pertussis, 506

Perverted appetite, 277

PetechiiB, 641

Petit mal, 736

Pf eiffer s bacillus, 902

Phagedena oris, 220

Phantom tumour, 263

Pharyngitis, 180

— acute catarrhal, 180

— adenoid, 181

— chronic catarrhal, 180

— follicular, 181

— granular, 181

— sicca, 181

INDEX

935

Phaiyngitis, treatment of, 184
Pharynx, new growth of, 187

— spasm of, 2&

— tuberculosis of, 187
Phlebotomus fever, 513
Phlegmasia dolens, 602
Phlegmonous sore throat, 187
Phosphatio diabetes, 431
Phosphaturia, 399, 480
Phthisis. 156

— acute, 139

pneumonic form of, 148

— chest in, 125

— chronic, 157

— etiology of, 161

— fibroid; 168

— physical signs of, 160

— sputum examination in, 901

— treatment of, 163

Physical examination of chest, 40
Physiognomy of disease, 16

in childhood, 20

Physiological albuminuria, 412

Pigeon-breast, 125

Pigment, alterations of, 641, 683

Pigmentary changes of the skin, 683

Pigmentation, causes of, 683

Piles. 328

Pill-rolling movement, 831

Pills. 913

Pituitary, signs of lesions of, 784

Pityriasis capitis. 689

— circinata, 658

— pilaris, 666

— rosea, 660

— rubra pilaris. 660

— versicolor, 684
Plague, bubonic. 507

— serum-therapy in, 538
Plaster mulls. 913
Plastic bronchitis, 156
Pleura, thickened, 171
Pleural effusion, 140

in cancer of the lung, 171

signs of. 131

Pleurisy, diaphragmatic, 120, 234

— dry, 138

— ■ with effusion, 140

Plexus paralysis, 811

Plumbism, 573

Pneumococcus, examination for the, 902

Pneumogastric nerve, 892

PneumoKoniosis, 170

Pneumonia, aberrant forms of, 148

— acute lobar, 144

— aspiration. 149

— catarrhal. 145

— chronic interstitial. 170

— hypostatic, 169

— lobar, diagnosis of, from broncho-

pneumonia, 146

— lobular, 148

— serum-therapy in, 538

— vaccine-therapy in, 638

Pbeumonia, tuberculous, 148
Pneumonic plague, 507
Pneumothorax, 150
Poikilocytosis, 551
Points of Valleix, 853
Poisoning by aniline derivatives, 39
Polioencephalitis, 814
Poliomyelitis, acute anterior, 847

— chronic, 849, 860

— subacute in adults, 849
Politzerisation, 889
Polyohromatophilia, 550
Polycythemia, splonomegalic, 38
Polygraph, the, 49
Poljmeuritis, 797
Polyorrhomeoitis, 251

Polypi, laryngeal, 194

— nasal, 206

— uterine, 443
Polyserositis, 251
Polyuria, 422

Pons, signs of lesions of, 784
Porencephaly, 796
Porokeratosis, 681
Portal obstruction, 258
Posterior basic meningitis, 773

— fossa, lesions of, 784
Post-nasal catarrh, 204
Post-tussic suction, 160
Pott's disease, 787
Powders, 914
Pregnancy, 447

— albuminuria in, 411

— extra-uterine, 445

— ruptured extra- uterine, 452
Presbyopia, 866

Pressure on bronchus, in aneurysm, 93,
172

— on trachea, in aneurysm, 93

— sense. 699

Primary lateral sclerosis, 795
Primitive myopathy, 861
Procidentia. 465

Prognosis, author^s method of, 11
Progressive muscular atrophy, 860

— neuro-muscular atrophy, 852
Prolapse of uterus. 466

— of vagina, 454
Proptosis, 865
Prostatic abscess, 417
Protopathic sensation, 698
Protrusion of eyes, 19
Prurigo, 662

— varieties of, 663
Pruritus, 663

— vulvae, 438

Pseudo -angina pectoris, 61
Pseudo-bulbar paralysis, 893
Pseudo-diphtheria bacillus, 903
Pseudo-hypertrophic paralysis, 24, 862

attitude of, 24

Psilosis, 325
Psittacosis, 514
Psoas abscess, 267

936

INDEX

Psoriasis, 657

Psorospermosis, 656

Psyohasthenia, 723

Ptosis. 865

Puerile breathing. 129

Puerperal eclampsia, convulsions in. 845

— fever, 525

— insanity, 761
Pulmonary congestion, 74

— embolism, 122

— oedema, acute, 140

— osteo-arthropathy, 638

— regurgitation. 78

— st^osis, 71, 75

— thrombosis, 122

— tuberculosis, 156. See Phthisis
Pulsating aorta, 267

Pulsation in epigastrium, 41, 235
Pulse, 48, 98

— anacrotic, 75. 105

— capillary. 77t 108

— character of. 99

— collapsing. 49. 109, 177

— Corrigan*8, 109

— dicrotic, 108

— examination of, 98

— force of, 99

— in auricular fibrillation. 82, 105

— in cardiac disease, 48, 81. 108

— inequality of, in aneurysm, 92

— in fatty heart, 104

— in prognosis. 110

— intermittent, 104

— in treatment, 110

— irregularity of, 104

— rapid. 101

— rate of, 99

— respiration ratio, 124
in pneumonia. 145

— rhythm of. 99

— slow. 102

— temperaturo ratio in abdominal

disease. 234

— venous. 49

— water-hammer. 49, 77, 109
Pulsus altemans. 105

— bisferiens. 105

— paradoxus. 106

Pupil. Ai^ll-Robertson. 870
Pupils, defects in. 869

— inequality of, in aneuiysm, 92

— in mediastinal tumour, 96

— reactions of, 870
Purpura, 684

— Henoch's, 618

— rheumatica. 618

Pus, bacteriological examination of, 903

— in urine. 417

— symptoms of formation of, 526
Pustular eruptions, 669

— foUiculitis, 671

— syphilide, 671
Pustule, definition of, 641
Pyaemia, acute, 523

Pyasmia, arthritis in. 617, 627
Pyelitis, 419

— calculous, 419

— tuberoulous, 420
Pyelography, 401
Pyelonephritis. 420

Pyloric obstruction, causes of, 300
Pylorus, hypertrophic stenosis of. 271
Pyogenic micro-oiiganisms. 903
Pyonephrosis, 433
Pjropericarditis, 54
Pyopneumopericardium, 54
Pyopneumothorax. 150
I^rorrhoea alvcolaris, 219
I^'^osalpinx, 451
Pyroxial disorders, classification of. 472

diagnosis of, 471

examination of. 468

Pyrexia. 459

— hysterical. 605

— symptoms of. 460

— treatment of, 541
Pyrosis. 277
lyuria. 391, 417

— tests for, 391

Quarantine, periods of, 461
Quincke's disease. See Urticaria
Quinsy. 183

Radiant heat in high Uood-preesure, 107
Radiography for detection of foreign
bodies in air-passagee, 191

— in chest diseases. 126

— in kidney disease, 401

— in stomach disorders. 280
Railway spine, 800

Rashes, dates of appearance, 4
Rat-bite fever, 513
Raynaud's disease. 607
Reaction of degeneration. 719
Recession of abdomen, 268
Rectocde, 465
Recurrent appendicitis. 248

— vomiting, 272

Red blood corpuscles in disease, 550

— vision, 867

Redux crepitations, 146
Reflexes, 715
Refraction, errors of. 866
Regui^tation of food, 227
Relapsing fever, 511
Relaxed throat, 187
Remittent fever, 619
Renal casts, 394

— colic, 245
Resistance of chest, 129
Retention of urine, 427
Retinitis, 879

— albuminuric. 380, 879

— pigmentosa, 879
Retinoscopy, 866
Retraction of head, 23
Retroflexion of uterus, 453

INDEX

937

Retropharyngeal abscess, 186
Retroversion of uterus, 453
Rheumatic fever, 631

— nodules, 675
Rheumatism, acute, 613

— chronic, 619
diet in, 302

— gonorrhceal, chronic, 625

— muscular, 688
Rheumatoid arthritis, 621
Rhinitis, acute, 201

— atrophic, 205

— chronic, 203

— diphtheritic, 203

— hypertrophic, 203

— syphilitic, 204
Rhinolalia, 748
Rhinophyma, 648
Rhinorrhoea, causes of acute, 201
of chronic, 208

— cerebro-spinal, 203

— diphtheritic, 209
Rhinosderoma, 683
Rhinoscopy, 200
Rhonchi, varieties of, 130
Rickets, 633

— chest in, 126

— foetal, 637

— spleen in, 376

— treatment of, 635
RiedeFs lobe. 264
Rigg's disease. 219
Rigidity, arthritic, 829

— hysterical, 825

— paralytic, 825
Rigors, 461
Ringworm, 686
Rinn6*s test, 887

Riva Rocci sphygmomanometer, 101

Rocky Mountain fever, 512

Rodagen. 213

Rodent ulcer, 679

Romberg's sign, 714

Rosacea, 648

Roseola, 646

— syphilitica, 646
Rossbach's Althemstiihl, 175
Rotatory nystagmus, 876
Rotheln, 489

Rubcoba. 489

Rupia, 671, 681

Ruptured abdominal organs, 240

Saccharimeter, Carwaidine's, 388
Sacral plexus paralysis, 811
Sacro-iliac disease, 458
Sahli's test, 254
Saline infusion, 576
" Salisbury " diet, 302
Saliva, decrease of, 217

— increase of, 217
Salpingitis, 451
Sanatorium treatment. 165
Sand-fly fever, 513

SarcinaB in vomit, 282
Sarcoma of skin, 677
Saturnism. See Plumbism
Scabies, 664, 666. 674
Scalp, diseases of. 686
Scaly eruptions, 657
Scaphoid abdomen, 268
Scarlatina, 473
Scarlet fever, 474

throat in, 185

Scars. 681

Schonlein's disease, 618

Schott treatment. See Nauheim

Sciatica, 857

Sclerema, 682

Scleroderma, 682

Sclerosis,*amyotrophic lateral,795,8a8,850

— disseminated, 832

— lateral, 795

— toxic combined, 796
Scorbutus, 581
Scotoma, 867
Scrivener's palsy, 825
Scrofuloderma, 679
Scurvy, 581

— infantile, 586
Sea-sickness, 272
Sebaceous cyst, 675
Seborrhoea capitis, sicca, 689
-— oleosa. 689
SeborrhoBio dermatitis, 658
Senile decay, 594

— tremor, 832

— vertigo, 595, 737
Sensation, common, 720

— deep, 699

— epicritic, 698

— joint, 701. 714, 721

— kinesthetic, 701, 714, 721

— muscle, 714

— perverted, 862

— pressure, 699

— protopathic, 698

— tactile, 720

— vibration, 699
Sense. See Sensation
Sensory tract, 698
Septicaemia, acute, 523

— chronic, 526

— serum-therapy in, 536
Septic jaundice, 350
Serous apoplexy, 745
Serum disease, 535. 645
Serum-therapy, 535

— in cholera, 538

— in diphtheria, 535

— in plague, 53iB

— in pneumonia, 538

— in septicaemia, 536

— in snake-poisoning, 538

— in tetanus, 636

— in typhoid fever, 537
Seventh nerve, 882

Shape of chest, variations in, 125

938

INDEX

Shingles. See Herpes Zoster

Shock, 733

SialorrhoBa. 217

Sick headache, 859

Sigmoid, tumours of the, 266

Singer*B node, 193

Single nerve paralysiB, 805

Sinus, thrombosis of cerebral, 775

Siriasis, 512

Sixth nerve, 865

Skin, diseases of, 639

— elementary lesions of, 641

— epithelioma of, 675, 679

— ffummata of, 675

— histological examination of, 640

— nodules of, 674

— physical examination of, 640

— sarcoma of, 677

— tumours of, 674, 675

— ulcers of, 677
Skodaic resonance, 129, 174

in pleural effusion, 141

Skull, anatomical considerations, 896

— variations in form of the, 21
Sleep, disordered, 707

— excessive, 709
Sleeping sickness, 529
Small-pox, 480

— modified, 484

" Snail track " ulcere, 185

Snake-poisoning, serum-therapy in, 538

Snoring, 206

Snow, carbon dioxide, 679, 681

Snuffles, 201

Solitary abscess of the liver, 355

Somnambulism, 709

Sore throat, causes of, 180 et 8eq.

Sound, uterine, 437

Spasm, causes of, 829

— clonic, 830
facial, 836

— habit, 836

— hysterical, 635

— localised clonic, 836

— of oesophagus. 230

— of pharynx, 230

— treatment of, 838
Spasmodic croup, 197

— tic, 835

— torticollis, 887
Spastic diplegia, 796

— paraplegia, primary, 786
Spectroscope, the, 557
Speculum, vaginal, 437
Speech, defects of, 747
Sphenoidal sinus, empyema of, 204
Sphygmogram, 100
Sphygmomanometer, 101

Spina! accessory nerve, 892

— caries. 787

paraplegia in, 787

— cord, extramedullary tumoure of, 787
haemorrhage into, 794

— . — intramedullary tumoureof , 790, 862

Spinal cord lesions, localisation of, 791

— meninges, 794

— mono^egia, 812

— pachymeningitis, 794, 82S

— segmoits, functions of, 788
Spine, embolism of, 794

— injury to the, 791

— neuralgia of, 869

— railway, 800

— tuberculosis of, 787

— tumoure of, 787
SpirocluDta ndlida, 569, 906
Spleen, amyloid disease of, 374

— atrophy of, 377

— embolism of, 373

— enlaigement of. 372

— e±amination of. 371

— floating, 376

— hydatid of, 376

— in rickets, 376

— in syphilis, 374. 376

— tuberculosis of. 374, 376

— tumoure of, 376

— wandering. 376
Splenic ansomia, 581
of infancy. 587

— fever. 492

Sfdeno-medullary leuk»mia, 557
Splenomegidic polycythjemia. 38
Splenoptc^, 376
Spondylitis, 458

— detormans, 625
Sponging in fevers, 542
Sporotrichosis. 677
Spotted fever. 510

Rocky Mountain, 512

Sprue, 325
Spur, nasal, 207

Sputum, bacteriological examination of.
901

— examination of, 133

— foetid, causes of. 176

— tubercle bacilli in, 902

— varieties of, 132
Squint, 873

St. Vitus' dance, 833
Stammering. 748
Status epilepticus, 841

— lympnaticus, 40
Steatoma, 675
Stellwag's sign, 865

Stenosis of larynx in ; yphilis. 193

— of pylorus, congenital. 271
Stiirs disease, 623

Stokes- Adams disease. IDS, 845
Stomach, atony of, 289, 899

— cancer of, 295

— classification of disease of, 285

— dilatation of, 299

— examination of contents of, 282

— gastralgia of, 291

— motor insufficiency of, 280

— palpation of, 279

— percussion of, 280

INDEX

939

Stomach, simple uloer of, 292

— succussion in, 299

— tube, 282
Stomatitis, 220

— paiasitic, 224

Stools, examination of, 308
Strabismus, 873
Strawberry tongue, 476
Streptoooooic skin eruptions, 669
Stricture of intestine, 336

— of larynx. 193

— of oeeophagus, 229
Stridor, congenital, 192

— in aneurysm, 93

— in laryngitis, 198
Stroke, 740
Stupor, 754
Submvolution, 444
Subphrenic abscess, 357
Subsultus tondinum, 23
Succussion, gastric, 299
Sudamina, 667

Sudden death, causes of, 39
Suffocative catarrh, acute, 138
Sugar, estimation of, 386
Sulph-hsemoglobinffimia, 38
Summer prurigo, 653
Sunstroke, 512
Suppression of urine, 427
Suppurative mediastinitis, 97
Suprarenal tumours, 265
Sweat, disorders of the, 686
Swelling of face, 17
Sycosis, 671
Symonds' tube, 232
Sympathetic system, 721

paralysis of cervical, 871

Symptoms, difference between subjective

and objective, 1
Syncope, 35

— in artorio-sclerosis, 737
SyphUis. 564

— arthritis in, 627

— bacteriology of, 906

— bone changes in, 636

— cardiac, 62

— condyloma in, 681

— congenital, 566

— convulsions in, 844

— Erb's paralysis in, 795

— eruptions in, 673

— hereditaiy, 666, 568, 592
facies of, 20

— gummatous eruptions in, 675

— insanity in, 761

— intracranial, 844

— joints m. 627

— lymphatic glands in, 603

— meningitis in, 782

— of choroid, 879

— of intestine, 323

— of larynx. 193

— of lips, 216
-— of liver, 365

Syphilis of lung, 173

— of s|deen, 374

— of stomach, 274

— of tongue, 223

— papular eruption in, 655

— pseudo-pandysis in, 627

— pustular eruptions in, 671

— roseola in, 646

— skull in, 636

— squamous eruption in, 659

— throat in, 185

— treatment of, 571

— ulceration of skin in, 678

— visceral, 522
Syphilitic rhinitis. 204
Syringomyelia, 862
Systouo murmurs, 74

Tabes dorsalis, 816
arthropathy in, 628

— mesenterica, 592
Tdche cir&mde, 771
Tachycardia, 101

— paroinrsmal. 59

Tffinia echinococcus, 132, 312

— mediocanellata, 312

— solium, 312
Tallqvist scale, 546
Talma-Morison operation, 460
Tarry stools, 328

Taste, bad, 275, 881

Teeth. 20, 218

Telangiectasis, 641

Temperature, subnormal, causes of, 470

Temporo-sphenoidal lobe, lesions of, 784

Tenesmus, 326

Tenth nerve, 892

Testamentary capacity. 763

Test meal, 282

with bismuth. 280

Tetanus, 827

— serum-therapy in, 536
Tetany, 828

Thermic fever, 512
Thermometry, 469
Thickened pleura, 171
Third nerve, paralysis of, 872
Thirst, causes of, 217
Thomsen*s disease, 829
Thorax. See Chest
Thrills, cardiac. 42
Throat, acute oedema of, 187

— causes of sore, 180

— clinical examination of, 179

— in acute specific fevers, 187

— relaxed, 180

— syphilis of, 185
Thrombosis, cerebral, 743, 779

— in extremities, 607

— of cerebral sinuses, 743, 776
Thrush, 224

Thymus, enlargement of, 97
Thyroid, disorders of, 209

— gland, atrophy of, 211

940

INDEX

Thyroid gland, enlargement of. 211

examination of, 210

Tic, 836

— convulsive, 836

— douloureux, 866

— non-douloureux, 858

— spasmodic, 836
Tinea circinata. 659, 666

— imbricata, 690

— tonsurans, 686

— versicolor, 684
Tinnitus, 891
Tobacco amblyopia 867
Tongue, acute oedema of, 226

— atrophy of, 226

— cancer of, 224

— fissures of, 226

— furring of, 222

— syphilis of, 223

— tuDerculosis of, 224

— ulcers of, 223

— warts of, 226
Tongue-tie, 222
Tonsillitis, 183

— acute follicular, 183
parenchymatous. 183

— chronic, 184

— in diphtheria, 185

— in scarlet fever, 186

— in syphilis, 185
Toothache, causes of, 218
Torticollis, 837
Toxsemic jaundice, 341
Trachea, forei^ body in, 191
Tracheotomy m diphtheria, 503

— in laryngeal paralysis, 197

— in Lud wig's angina, 187

— in oedema of glottis, 191
Trance, 762
Transfusion, 676
Transillumination, 205
Transverse myelitis, 793
Traube's plugs, 133

— space, 280

Treatment, general principles of. 12

— of skin diseases, 690
Tremor, 829. 880

— alcoholic, 832

— hysterical, 832, 835

— in cerebral tumoure, 833

— in metallic poisoning, 832

— post-paraljrtio. 837

— senile, 832

Treponema pallidum, 569, 906
Trichinosis, 313. 600. 680
Trichophyton. See Ringworm
Trichoptylosis. 689
Trichorrexis nodosa, 690
Trioocophalus dispar. 313
Tricuspid regurgitation. 76

— stenosis. 78
Trifacial neuralgia, 856

Trophic changes in nervous disease, 721
Tropical abscess, 366

Tiypanosoma. 655
Tiypanosomiasis. 589, 555
Tsutsugamnshi disease. 513
Tubercle bacillus, the. 901. 901
Tuberculin tests. 159

— treatment. 165
Tuberculosis, acute general. 520
of lungs. 139. US

— chronic, of lung. 157

— incipient, 575

— latent, 520

— of choroid, 879

— of larynx. 192

— of Ijrmphatic glands, 603

— of mediastinal glands, 97

— of mesenteric ^ands, 592

— of peritoneum. 250

— of pharynx. 187

— of skin. 679

— of spleen, 374

— of tongue, 224

— of the spine. 787

— tests for, 159

— treatment of, 164, 537

— ulceration of nose in, 204
Tuberculous arthritis. 627

— meningitis, 770

— pyelitis. 420
Tufnell's dietary. 95
Tumour, cerebellar. 824

— fatty, 675

— hepatic. 276

— intracranial. 781

— mediastinal, 95

— of abdom^i, 262

— of duodenum, 265

— of kidney, 266

— of skin, 674

— of spinal cord, 862

— of spine, extramedullary, 789

— of sjdeen, 372

— pelvic. 267. 452

— phantom. 263

— suprarenal. 265

Turbinate, hypertrophy of the. 207
Turkish batlis in dysmenorrhcDa. 441

in high blood-pressure. 107

in tremors, 8^

Twelfth nerve. 892
Twitohings, muscular, 837
Tylosis, &1
Tympanites, 266
Typhoid bacillus, the. 904

— fever, 494

serum reaction in, 905

— stote, 466
Typhus fever, 490
Tyrosin crystals. 351

Ulcer, doudenal. 295

— gastric. 292

— rodent, 679
Ulcerative colitis, acute, 318

— stomatitis. 220

INDEX

941

Ulcere, oausea of, 677
Unconsciousness, 738
Undulant fever, 508
Upper motor neuron paralysis, 786
Uraemia, 381

— convulsions in, 382, 846

— delirium in, 882, 464

— latent, 428

— treatment of, 409
Urea, estimation of, 389
Ureametor, Doremus", 389
Urethral caruncle, 438
Urethritis, 417

Uric acid, tests for, 390
Urine, acetone in, 393

— albumen in, tests for, 385

— albumose in, 392

— alterations in specific gravity, 422

— appearance of, 383

— bacteriological examination of, 904

— bile in, tests for, 390

— blood in, 390

— carbonates in, 399

— casts in, 394

— crystab in, 398

— diacetic acid in, 393

— diminution in, 421, 423

— estimation of chlorides in, 392
of salts in, 391

of urea in, 389

— examination of, 384

— fat in, 431

— incontinence of, 428
in women. 466

— indican in, 393

— inorganic deposits in, 398

— microbes in, 397

— mucin in, 386

— nuoleo-proteid in, 366

— odour of, 384

— organised deposits in, 394

— oxalates in, 398

— peptones in, 392

— - phosphates in, 398, 430

— proteids in, 392

— pus in, 391, 397,416

— quantity of, 385

— reaction of, 384

— retention of, 427

— specific gravity of, 384

— sugar in, 386

— sulphates in, 398

— suppression of, 427

— urates in, 398
Urinon^eter, 384
Urticaria, 641, 645

— pigmentosa, 686
Uterine hemorrhage, 442

— sound, 437

Uterus, displacements of, 453

— fibroids of, 443

— invereion of, 456

— malignant disease of, 444

— polypus of, 443

Uterus, prolapse of, 455
Uvula, elongation of, 180

Vaccination, 486

— preventive, in typhoid fever, 637
Vaccine therapy, 533

in boils, 537

in cystitis, 420

in gonoirhoeal arthritis, 627

in infective pyelonephritis, 420

in phthisis, 537

in pneumonia, 148, 638

in septiosemia, 536

Vaccinia, 486

Vagina, swellings of, 454

Vaginal examination, 438

— tumours, 454
Vaginismus, 467
Vaginitis, acute, 439

— chronic, 439
Vagus nerve, the, 892
Valves, position of cardiac, 47
Valvular disease, causes of, 80
of heart, 71

— diseases, differentiation of, 73
prognosis of, 81

symptoms of, 79

treatment of, 84

Vapores, 915

Vaquez' disease, 38

Varicella, 473

Variola, 480

Varioliformis, acne, 652

Varioloid, 482

Vascular alterations of the skin, 683

Veins, abdominal, dilatation of, 235

— varicose, 602

Venesection in chronic valviilar disease,
87

— in cerebral hsemorrhage, 744

— in pericarditis. 53

— in pneumonia, 147

— in uremia, 409
Verruca. See Warts
Vertebral caries. 787
Vertigo, 710

— aural. 737

— in arterial disease, 116, 595

— labjrrinthine, 737

— senile, 696, 737
Vesicle, definition of, 641
Vesicular eruptions, 661

— stomatitis, 220
Vibrio, cholera, 904
Vicarious menstruation, 274
Vinoent^s angina, 184
Visceral neuralgia, 246

— syphilis, 522
Visceroptosis, 253
Viscus, rupture of, 240
Vision, defects of, 866

— yellow, 867

Vocal cords, paralysis of, 194^
Voice, alterations in, 190

942

INDEX

Volsellom, 437
Volvulus, 335
Vomiting, causes of, 270

— cydieal, 272

— in hysteria, 271

— recurrent, 272
Von Graefe*8 sign, 865
Von Jaksch's ansmia, 587
Von Pirquet's reaction, 159
Vulva, diseases of the, 683
Vulvitis, 438

Warts, 680

— post-mortem, 680
Wassermann reaction, 906
Water-borne diseases, 540
" Water-brash," 217, 277
Water-hammer pulse, 49, 77, 109
Weber*s syndrome, 783

— test, 887
Weil's disease, 350
Werner's diagrams. 874
Wernicke's pupU reflex, 870
Wen, 675

Wet pack. 542
Wheal, 641
Whey, 304

Whey, white wine, 304
Whimpering pectoriloquy. 130
White leg. See Phlegmasia Doieos
Whooping-coujy^ 506
Widal^s test. 905
Winckd's disease, 342
Women, diseases of, 435
Woolsorter's disease, 492
Worms, causing anemia, 583

— intestinal, 316. 329
Writer's cramp, 825

Xanthelasma. See Xanthoma
Xanthoma, 685
Xeroderma, 661

— pigmentosa, 685
Xerostomia, 217
X-ray dermatitis, 650

— treatment in cancer, 590
in ringworm, 688

Yaws, 677
Yellow fever, 509

Ziehl-Nielsen method of staining, 902
Zona. See Herpes

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