-,-,- CONGRESS, UNITED MUls June. nuKcJ. uVlA^ CLINICAL LECTURES DISEASES OF OLD AGE S BY J. M. CHARCOT, M.D.. Profemor la the Faculty of |f< IIm Balpltritw*; Ifonbar of t of Hi udoti ; of tl -ih : of the Natural SciouoM, BriUMela; l'»e».dent of the Aaui .. etc. TIIANSI.\TED BY LEIGE II. HINT. i:.s,.. M.D.. Ij»lM)rai- • in l'iitholugy la the Medical Di \.-w V..r' WITH ADDITIONAL | BT ALFRED L. LOOMIS, M.D., Micnt of the New Totft .. f ; to the Central Di*|»eai>ital, etc., etc. NEW YORK W ILLI A M W O o I) . 6 O M P A X Y '27 Great Jones Btskei 18S1 ^ i NOTE. XXL U arc those deli by Pro£ I y Prof. J. pond wil numbering in II.. and III., ectively, of 1 nfl renumbered t'» avoid con- fusion, 1 Lth number XXI r. for the same iva>on. II. il. PREFACE. The few Lectures which I have been requested to add 1 by Professor Charcot on Diseases of Old Age, embody, in the main, the salient points in Dis- »s of Advanced Life which I have been accustomed to impress upon my classes at my clinic in Bellevue Hospital. They are presented in this form with the hope that they may prove acceptable additions to the very inter- ing lectures of Professor Charcot N ALFRED L. LOOMIS. 11 West Thiutt-fourtii Btb 'Kk. CONTEXTS INTBODUCTION. PAGE Empirical and Scientific Medicine — A Compari < n the Ancients and the 1-10 LECTUEE I. GENERAL CHARA< TILE PATHOLOGY. Objects of .1 from a Medi- ci] Poll '■ of iil«- Pathology — Pby _':ms an . tip culiar 1 1 ivus to the Greater Number oJ LECTURE II. TEH FEBRILE STATE IN Till: AGED. f Reaction in Old Acre — Organs seem to - rises — The G noticed— Fever in the Aged — What is Fever?- [mportanee of the Clinical Thermometer— Chill in Old People — Temperature u:\ r Pneumonia — The Practical Deduction! to be made therefrom— Defer . and Critical P« rturbations — Di6e;.- where the Temperature is Lowered iustead of Elevated 26-31 LECTURE III. [JLAR RHEUMATISM /: muttons Noueux) AND GOUT, PATHOLOGICAL BLOOD-CONDITTO I )UT. Frequency of Chronic Articular Rheumatism in the Salp Tophni d I.i:< V. PATHOLOGICAL ' ELetrocedent Gout; io«t Instances after an Autt>i>s\ m ge e ■ ih- roochial Chan ■ nlm — Sinn the I re urs li. VI. SEMEIOLOGY OF GO The Two Prin I alwaya eul in Appeal Sym >toiuN but | allowing Acute Gout — Qont Chronic, from \l. welopmeut of ■ V4-00 CONTENTS. IX LECTURE ViL SYMPTOMATOLOGY OF VISCERAL GOUT. Predilection of the Ancients for the Study of Pathological Metamorphosis — lui ;icism of the Moderns — I' .. G<»ut — Functional Dermi Lesions — Masked, M Retrocedent Goat — OsJD Gout exist Inde- pendently of all Articular of the Digestive (anal — gas— Dyspepsia, Cardialgia, Goaty i Bepatio Evident - of the Heart and ;: - Its Intlu- eni' ira- tory Byatetn kathma -The Urinary Passage! I 1 1 of . the Kid- ■ N< plirn- IndieuUouoi: ■ .-eases whieh accompany Gout 01-71 LECTURE VIII. 00* vr DIB] iSBB OF 001 Anthrax — Grave Phl< • as — Di no — Inti roar* rent Dieoasi I're- with. if ana In- tea Aasociut I in the and Cancel ; of Goat ajid Lh 72-80 LECTURE IX. ETIOLOGY OF G< I Cottdittam 'iont — Suitable Follow in Making this Kind | ration [nconT e nienoa of ' hemical and 1 d Theories — - which have them — I! An- tiquity lease — Wr. Diminu- ti<- »— Modi- lo rlsbitl noes — .M llv in England and in - , — Almost wiu.i:. analytical Study <>f the Causes of ige Tempo- ral! Want of ■ esses — Ferrntnted Liquors : Ale, Porter, \\ n.e, and i ider — Exciting 81-91 APPENDIX TO LECTURE IX. English Beers 92-94 x coxte:- LECTURE X. PATHOLOGY OF GOUT. Rational Theory of Gont — It can harf I — A i < menl n of Zali :} — Km - -ia ill the Oft] ! our KnOWled rrt-seiit L>.. XI. CHRONIC ARTICULAR KB Ohionic; Articular III .-> of the tfalad, & Cbx< ' matistu - S the I terisl me ; in thi v.: : • , :■ - . I.i [I. OOKP&RIS OTl . AMU'OlN Analogy between the tism \\ th Exudation — The Intlami as of the Articular i poured our into ; of Chrouio Rheumnti from thritis Syj.liilit Ghron c Rheum Cau» — Chronic Rheumatism, in thi .»-115 CONTEXTS. XI LECTURE XIII. ACUTE ARTICULAR RHEUMATISM CONSIDERED ESPECIALLY IX ITS RE- LATIONS WITH CHRONIC AETICULAB RHEUMATISM AND G> ription of Acute a :hcumatism— Analo- - with Chronio Rheumatism — Dill- r arating it from Goat — Acute nmatiam : fill- ing The i the Nun. — J iut, ami .Subacute Art.culur Rheumatism 1 10— 1~2 i tiki: xiv. KRAI AFFECTIONS l' I 1 thor-o i • till tin the i Hi- ll — Astliii A 1 ' | ] . LECTURE XV. BYMPTOMATOLOG BBONIC P» kBTIOULAB RHEUicA- nsii ic Articular Rheumatism — In Reality Con- ilar Kh< tly Confounded with <;■ from which i I in the Smaller Joi at the C< mmi of — l'ermam Xll CONTEXTS. — Pain— Crackling— Bony Deformities— Joints which are Preferably Affected — The Hands almost always the 1 Invasion — Mode of Succession of Cases of Arthr t ently Generalized from the Commencement — In OM -*ive Course — Consecutive Deform il Varieties- I rm— (Edematous Form- I -—Of the Vertebral Column — 1» i the Joints — Mode of Product: odic Contracti' I auses — G* neral Reaction— Rapid Development LECTURE XVI. SYMPTOMATOLOGY Of PARTIAL OHB0K CD OF HR- BBRDE3 Partial i volv — Articular 1» I — Articular P : apanies the KliL-um . I locndi aeatt >«iues of the tie— though xcry ra. .VII. ETIOl The Principal Canst all the Forme of this Dis«a-<" and 1 ■ likewise i ■ Chronio R Wei I tj .:* In- rr— The \ .• ■ < las ■otioae — Btartoo — p 1 V.-h i$-l» CONTENTS. X1U LECTUEE XYIII. TREATMENT OF GOUT AND CHRONIC ARTICULAR RHEUMATISM. PAGE General Considerations Concerning the Treatment of Gout— Treatment of the Attacks or Paroxysms — The Expectant Plan — Quack Remedies- -Colehicum — Advantages and Disadvantages of this Agent — Rules which should Govern its Employment— Naro tia : BjCOOj a imM and Opium — Sulphate of Quintal — Iodide of rntiiinni Tlnntnin of Guaiacum — Topical Ben .jent of the Constitnl Various twam, Lithium — Action of t: ■ » — Oontraindioated — Mineral Waters — Tonics and machics — Treatment of the L .Ik-Stones and Rigidity of Joints— Treatment of Abnormal Gout— 1 meat of Chronic Articular 1 r Knowledge upon this Su urn. Sulphate of Qainia, Bloodletting — Alkalies — Tinotoie of lo<: tally and v — Tincture of Guaiacum — Iodide of Potassium — Ir I J Waters— Medical Art Fowerieai In the Majority I . 1 00- 1 80 APPENDIX. CLIN! THERM IX OLD AGE.' tiki: xix. Importance of Clinical Thermometry in General — Its Aj to Senile PathoL . .! AL-idity Normal am: Patho- cal < 'ondi — Low, Linm. and High r from High Tern] wL :i ( .f Time B of the Dai nrenee — P).. I Expcriii.- from Lowering of the Temperature 166-170 LEOTUBE XX. Thermal Characteristics of Febrile Diseases in Old " the Continu.d T\ -eases of the Remit • -Febrile I of tin- [ntermittenft Type- Rapi . • ntral Temperature, at thfl Time of Death, in Certain D I'. taniu — Hysteria — Cerebral Hemorrhage and Softening — Epileptiform and Apoplec- tiform Attacks H tures delivered by J. M. Charcot, in th< xx.. and xxi.. arei., ii.. and iii. of the Appendix, renumbered to avoid confusion. — L. H. ll.j xiv oosmai LECTURE XXI. Central Algidity — The Disagreement that ma Between the External and the Deep Pa — Cancer, Aneem in l of Drug- — ix. Peritonitis— D •■ Algid L'ufjuinouia- I -4-193 .II.' SEN! I itomy— Symptoms— Etiology. ;;i: win. Diagnosis— Prognosis — Treatment.. 900-906 TI UK XX U. Terential Diagnosis— Progr.o-. i.i-:< xxv. toms— Differential Diagnosis — Prognosis — Treatment ui m LECTURE XXVI. Sympt agnosia— Prognosis— Treatment M S - W O ug Lectnrea are by Professor Alfred L. Looaaia, of Nan ^ CONTEXTS. X V LECTURE XXVII. * CEREBRAL HEMORRHAGE.— APOPLEXY. Moibid Anatomy — Ed Symptoms — Differential Diagnosis — Prognosis — ament — Cerebral Softening — Bai at — Morbid Anatomy— 1 ology 881-837 LECT! Will. CEREBRAL SOFTKN! Symptoms — Differential Diagn< >sis— Trt Atro- . —Morbid AnAtomj I Chmngei in tin- Alimi d! omj LECTURE XXIX. (HI: \TAKK1I •gnotui — '1 : LECTURE XI Constipation in <>M Aft ''rog- no.v mgea in tl- it >gnoaia— 1 . -Morbid Anat« LECTURE XXXI. ilk BTPEBTBOPHI OF Tin: PB06TATS (.land. •>ras— Dilf. k— Dcfini- ti" -.iiny— Ku .ptoius — Differential • at 21 CLINICAL LECTURES ON THE DISEASES OF OLD AGE. INTRODUCTION. EMPIRICAL AND BCIENTH vim a N < DENTS and Tin; HODBRNa y inaugurate is purpi i quaint you with tl thai distingui athology from that of adults, and to tix. y< which are mi I with in asylums i Cor the Within as close lu I by a method which is Buitahlel tacal instruction. We shall Dot, however, neglect the clinical aspect ; and I hope, indeed, to be abl • ;. at the 1" -1- . some of the types which i - of our descriptions You are dow acquainted with the obj< ei tidies ; and wi nt once commence with thi t, for I am of Condillao'a opinion, and I think thai considerations general in then than at its beginning. Still. th( 1 i>sic:d tradition, as it were, which pu1 nnder the obligation to explain himself at the very commencement in a more or forical manner upon certain fundamental ion, to make a profession of hi iief. I do not think I ought to i Kempt myself from this obligation, and shall courageously enter upon ti plishment of this task— often thank always difficult — reckoning not a little upon your indulgence and upon the kindness which you have so often shown to D Ther 'tuple, and, so to speak, natural means of broaching these 1 and important questions : it is to inquire as to how. in the court the progn ssive deTelopment of scientific culture, they have become known and how they have been settled; in this way 1;. comes a means of criticism. Now, in following that path, it will soon become very clear to you that pure observation was never attained at any epoch without supreme efforts having been made to prevail over the spirit of hypothesis. V CLINICAL LECTURES ON As for that which especially concerns medicine — and with this we are alone occupied here — even the most stoical minds have never confined them- selves to the mere statement of facts, but have sought to make a common bond of union between them by means of some theory. From the very commencement we see the mind of man occupied as much, nay more, with the subjective relationship of things than with their reality ; the data furnished empirically by observation, when still but re- cently obtained, are brought together in a class — tested, one by the others, in order that systems or theories may be derived from them. 1 In this, it must be confessed, lies one of the necessities of the human mind, and, according to a celebrated saying of Kant's, it seems that our ideas are forced to cast themselves in this common mould ; and it was pre- cisely this which was recognized by the founder of positive philosophy him- self, who will undoubtedly be reproached by no one for having opened the way for hypothesis, when he declared that, even if a theory is to be founded entirely upon observation, it must still from sheer necessity be guided by some theory in order that it may yield to observation a profitable result. The real wants of our minds can, however, always be distinguished, in this connection, from the manifold exaggerations with which systematic thinkers allow themselves to become involved. Hence we see in reality the existence of a method of speculation which is grounded strictly upon facts, as well as the existence of a method of observation keeping aloof as much as possible from premature speculation ; and the whole question conse- quently resolves itself into the discovery of a common ground whereon these two methods can meet. Gentlemen, viewing matters from the point which we occupy to-day. I think that we can discover a radical difference between ancient and modem medicine. The first has always been deficient in those elements necessary to the construction of a positive theory, and for this reason the numerous attempts which it has made in that direction have of necessity signally failed. Modern medicine, on the other hand, possesses some of the matt rial that could serve such a construction ; but. profiting by the mistake made by its predecessors, it knows above all what paths should remain impervious to speculation, and it likewise knows what tracts it may survey without falling into error. I shall endeavor to develop this theme in the course of the present lecture ; but, first of all, we must be acquainted with that time in history when the old system of medicine ended to give way to the I I. — In our day a profound, a radical revolution has occurred in medicine. It would undoubtedly be necessary to go back to far distant tin. order to discover the first origin — the point of departure— of this mighty change, whose influence we still feel to this day. But the direction of this movement has been distinctly marked out, and its aim has been most brilliantly set forth, only toward the end of the eighteenth and the I ning of this century . It would be going quite too far if we were to say that an unfathomable abyss opened just at that period and separated the medicine i from that of modern times. No : traditional ties are not sundered : the labor of times gone by is not lost ; and we shall treasure up the immense 1 Dechambre : Introduction to the Dictionnaire Encyclopediquo u^ I M6dt- cal« j, p. xix. THE DISEASES OF OLD AGE. 3 heritage which our predecessors accumulated in the course of centuries. Still, it must be confessed that new horizons have opened to us, and that the views of modern science are from a standpoint which has risen as it has altered. The forerunners of this reformation were Vesalius, Harvey, Morgagni, and Bichat, the creator of general anatomy. Corvisart, Laennec, and Broussais co-operated to a very great extent in the movement ; and now come our immediate teachers, and it is with pleasure that I ask you to ob- serve that all these names are names of Frenchmen. It appears that the marvellous progress made by experimental physiol- ogy in these later times, under the influence of Mtiller, Claude Bernard, Longet, and Brown-Sequard, has finally brought over even the tardy and the timid, and settled the question. The essential characteristic of this revolution consists in the direct, the immediate — and we will say legitimate — intervention of anatomy and phys- iology in the domain of pathology. Before the period when this revolution occurred, medicine was almost wholly restricted to the study of symptoms ; after that time it became, in succession, anatomical, then physiological, and next acquired decided scien- tific tendencies. The fundamental principles accepted by modern medicine can, I think, be asdribed to two characteristic features. In the first place, symptoms which used to be considered in an abstract manner, and, to a certain extent, apart from our organism, are to-day inti- mately connected with it ; according to Bichat's precept, the seat" of the malady should be sought for. The inflexible logic of Broussais forced him to proclaim that he knew of no derangement of function without a corresponding lesion of an organ (we should rather say tissue to-day) ; symptoms, then, are in reality noth- ing but the cry from suffering organs. In the second place, it was possible for the ancients to consider disease as a thing independent of the organism — as a sort of parasite clinging to the economy ; while to-da} r — and again to Broussais we owe it for having succinctly asserted the principle — it is merely a disturbance of the inherent properties of our organs. It is here no question concerning the appear- ance of new laws, but only of the perversion or derangement of pre-existing ones. We recognize the enormous part which the sciences of anatomy and physiology are henceforth to play in the interpretation of morbid phenom- ena ; but is that saying that these' two branches are to absorb pathology and rule it with an absolute hand ? Gentlemen, a serious difficulty, demanding discussion, presents itself at this point, and I ask your permission to enlarge somewhat thereupon. It is absolutely certain that pathology can be greatly illumined by physiology, but it is just as certain that it cannot be deduced from physi- ology. Allow me in this connection to recall to your minds a profound thought which is found in Hippocrates : " Who could have foretold," says he, " from the structure of the brain, that wine could derange its functions ? " M. Littre, who quotes this passage, adds the question : " Who could have been taught, by his knowledge of the human body, that the emanations from marshes would cause intermittent fever ? " It is, as you see, a complex problem. Really, in addition to the physiological condition supposed to be known, it is likewise necessary to search for the manner, which is in- 4 CLIXICAL LECTUEES OX fluenced by the action of the morbific cause. In other words, in order to know what will be the effects of any morbific agent upon a healthy organ- ism, it is indispensably necessary that experiment! shall have been made. Thus you see that pathology, hi the jnesence of anatomy and \ ology, has the right to preserve a certain degree of independence, and to possess a certain amount of autonomy. A pure and simple - pathological facts evidently furnishes us with data of th< tance, needing no rapport other than that they furnish o( those, so to speak, constitute ti 1 of medicine — a The intervention h< n of biolof IS without - usable, including, too, the physico-chemical ba . hich an lith biology ; and in default oi be made at random, us if w< I in the dark ;' still. U deeply pathologica] observation mb- ordinate one ; th< lines, and wishes to ooofi] consideration of them in their natural relationship. ih true character of empirical m< dignity of its etymological by that title the - ncinc wh< lte, and in a period when re not unit logical tin i \v | _ ;.:: ganization, and into the i mall have unveiled all I understood every modinc LOiny — that il reality is far. very far, from approaching this anatomy its. If, all are in process of B fo luti Hi DOB, 1 think t: that nave been m< 'cinatical. :.d. win'.. avoid, as Borden aaya, a forced and unwilh- empiricism, With tl ■ ense ser- renden fchology 1 physiology, ami to boldly assert that in it lies the ful I besides, out which ought to he accorded to pi they Lacked more exact and t v lema which they sometim t< rmined their profoundness. have striven to interpret pathological fa the physiology then in vogue. iinieal oba In our tini« s KD P**t con: ! anatomical and physiological science.*' (Ch. Robin: J oaraai del' Anatomic, eta, . p, 8870 - ad actioi bus Lh aaturaui u:orbi inde ueccss&rio sequentia.*' THE DISEASES OF OLD AGE. Just here allow me to repeat to you the very words of Dareniberg, who gives his opinion on this point with all the authority which a thorough knowledge of history imparts. He says : " Nothing is better than a good physiology, or at least a physiology which, grounded on experience, still carries within itself inexhaustible germs of perfection. Such a physiology reforms medicine and transforms therapeutics ; but, again, nothing is more disastrous, more opposed to the progress of pathology than an unsound physiology, than an " d priori " physiology, which daily finds in itself the best reasons for plunging deeper and deeper into obscurity, and restraining the flight of science. It was in vain that the most dehcate and difficult observations multiplied in the Hippocratic school at Alexandria ; ideas arc more stubborn than facts. Physiology resists so bravely, that it miscon- strues the discoveries of anatomy and the conquests of pathology, in order to bring them under its laws. Very different was it when beneath the hand of Galen the experimental method, already touched on at the Alex- andrian school, transformed the physiology of the nervous system ; then the whole aspect of medicine changed.'" ' Now, gentlemen, that " d priori " physiology alone is responsible for those too notorious systems which, at various revivals, hare excited such a baleful influence upon the development i — Naturalism. Stahlism — ' and all the forms of ancient and modern vitalism, not excepting that of Bichat, touch it on the one side ; and iatro-mechanism ' and iatro-chemis- try, 4 on the other. The firmer take away the principles of life from the organism, so that they may govern it as would a capricious ruler ; while the others daringly attempt to give a physical or chemical interpretation to lite, and this, too, at an epoch when the real relation of biology to the physical sciences not even surmised. Happily, such errors are impossible in our times Placed upon a solid basis, physiology can no longer be dangerous to medi- cine ; on the contrary, it has become its most solid support It encloses it on every side, if I may n pression, in a net-work with compact meshes, no longer permitting rash speculations to pass through it ; and even if, in our times, errors are yet committed in some instances, they only evince a faulty application of the method, and not an error in principles. AVise and well-balanced thinkers have, always energetically protested against usurpation by an unsound physiology; and from this standard we must look with admiration upon those physicians who were devoted, on principle, to the cultivation of pure observation, from among whom towers the mighty form of Hippocrates in the foremost rank. Gentlemen, what are the products of that medicine systematically isolated from all extraneous contact, and consequently reduced to its own forces, and founded upon pure observation? What is its character, how much may it claim, where does its province end ? Here are questions that certainly deserve to be examined. History offers in this respect a series of experiments made for us. prolonged over the several centuries, and whose results are to-day offered for our estimation of them. 1 Ilt'sume dc THistoire de la Medecine, etc.: Union Medicale, 18G5. 2 Stahlism: the "■ phlogiston theory." — L. H. 11. 3 Iatro-mechanism : a svstem of treating diseases by the application of mechanical forces.— L. H. H 4 Iatro-chemistry : a system where diseases were treated with chemical prepara- tions. — L. H. H. 6 CLINICAL LECTURES OX LI. — But this leads us back into the vers* midst of antiquity, to the best days of Greece — to the time of Pericles. ' In this epoch anatomy was in a most rudimentary condition ; the nervous system had not as yet been distin. Erom the tendinous struct The brain was considered a gland. They thought that the filled with air, and the real distribution of the veno' ifi wholly unknown. Physiology was even below this level ; it was grounded only upon fan- tastical notions ; it had not i from tl t< .tive philosophy of that period, which, in ill knowledge of the universe, ign and e\( u thought this alii. error of Greek philosophy which had produced such dazzling applied to Objective reality, and tli most evident axioms were d< In the midai the Bohool of ( tea 1 spring up. I directed against the Cnidian 4 phyaiciai] the philoa >phy of tl i medicine should | h\ pothesis ; and in this way 1; miration of every It can be compared fa bj masters who had only have not vet learned to surpass, with all i Hippocr lines, without pretendi] He thus views it in its k r to as- m the modifications which it undergoes boa This Last standpoint leads up where the intluee that I nd out in bold relief. As the 3 -es successively through ti- the dry and the W< doctrine of medi< pherio conditions, a doctrine which still rations which it lias sum red. Wear- it. Climate, as it w« ; more marked since its inihu i. and free, if the Asiatic nd slaves mate in which th- >u see, is the geographical fatalism— a d tunes by Herder, and worked up with so mueh skill under the title oi tl.. ment " (Tneorie dea milieu who can question the infill 1 In this pnssag-o 4 it will be eu; sxoellent explanatory inn ...o works >. . nlc do 1;\ Philosophy I in the .1" l>ocratc8. — L. II II 'Onidoa, an island i L U. 11. THE DISEASES OF OLD AGE. 7 and mind, find above all, upon diseases which may affect us ? Following* out this analogy, Hippocrates looked upon ages as the seasons of life, and consequently attributed special diseases to them. Without accepting this interpretation, modern science has still fully confirmed the truth of the fact, and we know that there are diseases which pertain to the different periods of life. That which attracts us at the onset and impresses us most strongly in the Hippocratic pathology, is the importance he accords the general con- dition, and the indifference he exhibits witli regard to the local state of affairs. This point of view will appear singularly exclusive unless we re- member the conditions under which Hippocrates made his observations. He concentrated his attention pre-eminently upon acute febrile diseases, and, as M. Littre lias remarked, without doubt more especially upon the remit- tent and pseud- )- continued fevers which are as prevalent in Greece to-day as they were in the time of Hippocrates. Now, it is a recognized fact that fever almost always involves the same state of the system, independent of the causes which produce it and the different forms it may assume. But that which, according to Hippoeral >f prime importance, consisted in discovering certain signs which enabled mptoms, and the ter- mination of the disease to be fo and which furnished indications for the exhibition of remediea It was to attain this end that ho attentively examined the features and the color of the face, the attitude of the patient, the he it of the body, the respiratory movements, the urine, sweat, and the various evacuations. Is it not with almost the same end in view that we try to rind out the state of the forces, the amount of arterial tension, and the oscillations of the i tral temperature, when the local condition it furnish useful indi- cations? And the theory of erii after en. luring the stern test of modern criticism, has still survived, though stripped of the intentional character ascribed to it by the ancients. You bleinen, from this rapid outline of the pathology of Hippo- crates, what results the method of observation may Lead to ; the facts gath- ered by it, and views it has proved, resist the action of time. They have reached us without having lost any of their striking truth. And we further state that, without transgressing its legitimate prerogative, this method may ueral views and furnish data of a superior order. If in reality there exist an observation especially analytical and limited to detailed facts, in which the moderns have noticeably excelled, then ition on a grand scale, more familiar perhaps among the an- cients — one which is not confined to the examination of isolated phenomena, but which views them, on the contrary, in their mutual relationships, in their order of succession : such, definitively, as nature offers to him who knows how to view things from a somewhat elevated standpoint. Thus we have come to recognize that every disease has its own evolu- tion, a special manner of development, a peculiar series of symptoms, which allow a description to be made of it after a common type in the midst of variable, accessory circumstances. Thence has issued the idea of unities or morbid species, a notion per- fectly correct since it corresponds to a fact of experience, but the significa- tion of which has been strangely altered when things have gone so far that diseases are regarded as concrete beings liko individuals, by the same right as an animal or a plant. W« know now that a disease sometimes runs rapidly through the sue- 8 CLINICAL LECTURES OX cessive stages which are part of its natural history, to reach its termination ; and we know that sometimes, on the other hand, it requires a long space of time to pass through its various phases of development. Thus arises between acute and chronic affections a distinction which evidently answers to the results of clinical observation, but which ought not to be looked upon as a line of absolute demarcation, since the acute and chronic form of one and the same pathological condition often merge into each other by imperceptible transitions. We have further seen, by observations which have multiplied, that va- rious morbid states coexist or succeed one another in the same person or in the same family, following a definite order and after certain laws ; and hence it has been concluded, by a very simple process of reasoning, or rather by direct intuition, that those diseases were not isolated, and that they must unite in a common cause which served for their bond. In this way the grand conception of constitutional diseases and diatheses was pro- duced, and this idea originated in pure observation. Hypothesis does not commence until the moment when, in order to attribute existence to this unknown cause, the mind, following the bent of the day, has now ascribed an influence from the nervous system, and now a modification of the of the humors, or the presence in the blood of some morbific material. In the course of time, analytical has succeeded synthetical observation, which has not, moreover, been always neglected. And thus, as the world has grown older, science has been successively enriched by an immense number of general or partial facts, which positively constitute the only tra- ditional medicine that commands resi "We have now arrived at the limit of this rapid review. The examples I have given are sufficient for us to appreciate the resources of the method of observation applied to medicine, even when it voluntarily confines to the sphere of the external phenomena of disease, that is to say, the symptoms. But it is easy to recognize at the same time that a pathology thus de- prived of its natural support can amount to nothing, even in the most skil- ful hands, but a more or less elevated empiricism. It is that which un- doubtedly constitutes the common, the fundamental course of all scientific construction, and it has even been possible to establish upon such a a practical medicine which nothing hinders from arriving at a certain de- gree of perfection. But the work remains incomplete, and the human mind, urged forward by an irresistible force, is not able to stop by the way. The efforts it has made to finish its task have of necessity been futile so long as anatomy and physiology were not established. And tins should make us indulgent toward those systems which have anoc from antiquity to our days. But at last the time has come, reform complished, and we may now appreciate what fruit it has produced and foresee what it will bring forth in the future. m. — Clearing with a single bound a period of two thousand years, we are now to confront the results of pure observation with the work of the mod- ern mind, armed with all the means of investigation which it to-day sesses. And to render the contrast more striking, we shall pass over in silence the transition epochs so as not to be busied with anything except the scientific movement properly belonging to tins, our century. You have, gentlemen, no doubt heard mention several times of a pathological anatomy, as opposed commonly to the pathological anatomy THE DISEASES OF OLD AGE. 9 of the ancients. It is proper that we should at the very onset distinguish what each expression signifies. I shall speak just here of an historical point to which I ought to direct your attention for a moment : it is quite recent history, for it is not so long since pathological anatomy asserted itself for the first time as a special branch of science. One of the first attempts at systematization which be- came law, dates from 1812. The statement of the doctrine — its code, as it were — is found recorded in one of the first articles of the great " Diction- naire des Sciences Medicales." This document, precious on so many accounts, bears the signature of two illustrious men — Bayle and Laennec. I wish to attempt, gentlemen, to characterize in a few words that first- named pathological anatomy which has for half a century held undisputed sway. , Its means of investigation are very simple : it takes the word anatomy in the rigorous exactitude of its etymological sense, and knows nothing besides save the scalpel. For it, the alterations occurring in organs can be determined only after changes have taken place in their relations, volume, consistency, density, color, and general aspect. It is impossible, as a general rule, to look for characteristics of modifi- cations in texture, since this is almost always ignored. What efforts must be made in order to establish the identity of an anatomical type with the aid of such data ? But the masters surpassed themselves, and produced in this manner more than one inimitable model. In spite of all things, every one understands how difficult it is to fix in the mind such fugitive traits as those, for example, taken from the aspect and the color. These have shades and contrasts which the most picturesque language finds it difficult to express. Thus the anatomo-pathologist has many times felt the need of becoming an artist, or of invoking the aid of the stranger's pencil. It is quite natural that art should intervene here, where the figurative side has such great importance. To its co-operation we owe more than one precious collection, and, above all else, the imper- ishable monument erected by Professor Cruveilhier, under the name of "Atlas d'Anatomie Pathologique du Corps Humain." From the commencement it was foreseen that a day would come when all the lesions that the eye could not perceive would be definitely described, classified, and catalogued. It was thought that then the work would be fin- ished, for it was not known from what side improvement could come. That is undoubtedly why the heads of the school did not dream that their science would play any but a very modest role in the whole sphere of pathological science. They even at all times endeavored to circumscribe it within nar- row limits, as if they wished, by this means, to preserve it from all the allurements which might have compromised it. In the first place they hasten to declare that their anatomy is applicable only to a limited number of diseases, since many of them do not possess lesions which are appreciable by its means of investigation. And further, even in the domain of organic diseases, where it would seem right for it to obtrude, its part is still not a very ambitious one. Indeed, the object is, above all, to enrich nosology with new lights, allowing discrim- ination between diseases the analogy of whose symptoms might have led to their confusing. The distinction being stated, the end was attained ; for pathological anatomy voluntarily limits itself — and on that point is fully resolved — to the viewing of lesions by themselves, independent of the symp- 10 CLINICAL LECTURES ON toms which accompany them. It is not necessary to look for any explana- tion here concerning the proximate cause of disease, or th. its formation. Such, gentlemen, if I do not mistake them, are the most original fe: I of this pathological anatomy, thai 1ms sometimes been ironically c dead anatomy." I have not i Lieve that at least I have faithfully portrayed the tendenci r i'li< or imitators I resaed the limits which they imposed upon I rw the tracks of their brilliant incur sioi he closed to pathological anatomy. The method stood, DO : hut the me: was near when it wis to undi V.mi are acquainted, gentlemen, with t irhiefa tk§ anatomical school — for by this t i 1 1 Heine, with those limited and circn This is a point upon which i' > show that, even to this day, notwithstandh in various directioi all their author all their • naked eye, such as it has instituted, and like ti it made, will always constitut investigation must pass. m such c atomy can be called upon t i expand and develop it, Gentlemen, if I by the first pathol< sician /" think My. When circun evolution possible, . wholly renovated pli periiuent.il channel— tin then definitely fulfilled by I microscope. Then n:< n vin i' .08 an autopsy exhibits, with which it was the livin tic vl by the morbid condition which must be reconal physiological i pha-t s. often the List, oi :i back in order to p utline oi the i elves will confess that it would \v.v were it not for the co-operation of his Thus, as we have seen, th rinciple stops, as a matter of course, at the Bin in the study of lesions, it estima- tion by any systematic idea. alone is not simply I . a doctrine. 11. analysis m meni THE DISEASES OF OLD AGE. 11 It is in these elements that the conditions of incomplete life may he truly said to reside ; an organ is hut an aggregate, a collective, a resultant ; and hence, hy the aid of the microscope and reagents, we must penetrate to the elements in order to get at the modifications which they undergo from the influence of morbific causes, and from these modifications to deduce the reason of the derangement produced in the whole organ. Thus, gentlemen, pathological histology, from which histo-chemistry is inseparable, has not its sole aim in a limitation of the number of non-mate- rial diseases, by showing that lesions may be present where the eye cannot perceive them ; in furnishing new means of diagnosis, new nosological characteristics ; neither is its part restricted to the unveiling of the hidden reason of anatoruo-pathological forms, recorded and classified by micros- copy, and to affix a more lasting and scientific characteristic to them, by ascribing each one to its corresponding modification in the texture of the organ ; its aims stretch still farther, for it also has for an object a kind of intimate pathological physiology, which, as it were, follows step by step the various phases of the morbid process in each elementary part, striving to avail itself of the least transition which binds the pathological to the nor- mal state. On this side you see that pathologico-histological anatomy touches on patho . or rather mingles with it, and at the same time also allies itself to physiology, which in this special direction takes the name of patho- logical physiology. Now, gentlemen, it is important to notice — for it is a characteristic fea- ture — that the end which pathological anatomy proposes to itself cannot bo readied without establishing an incessant a pproximation of the lesion that is studied even to the minutest details of its development, and the patho- logical circumstances minutely observed at tin- bedside. And in this man- ner, as a consequent obligation, as a logical necessity, pathological anatomy, in proportion as it penetrates more deeply into the intimacy of tissues, b - comes simultaneously more animated and living, tending toward a closer union with the clinical. However, gentlemen, in the face of a manifest functional derangement whose seat is indicated by physiology, histological analysis often remains even yet powerless to state what material vice corresponds to the disturb- ance of function. Is that saying that we must resign ourselves to the belief, contrary to all analogy, that a functional lesion, a derangement of organic properties, can exist without any corresponding material modifica- tion ? As for myself, were the question urged upon me, I should not hesi- tate to place myself by the side of l\eil, Broussais, Gorget, and many other eminent minds ; I would recollect that, even in the normal performance of the functions of life, the labor of the organs is not accomplished without a material change taking place — a correlative destruction and reparation. Every function tends to destroy the instruments by means of which it is performed. Muscle in a state of repose has an alkaline reaction ; it becomes acid when it is tired. An analogous modification has been observed in the nerves and the spi- nal marrow, and even the cerebral substance itself is, according to Heynsius and Punke, acid when the individual is awake, and alkaline during sleep. Such examples as these show us that in the anatomical elements the main- tenance of life is closely bound to the existence of an incessant molecular work which manifests itself by appreciable chemical phenomena. Is it not easy to conceive the existence of lesions of elements which, without altering their form, hinder that organic movement in the absence of which their 12 CLINICAL LECTURES OX functions cannot be performed? "Without altering their form, carbonic oxide robs the red blood-corpuscles of their power of absorbing o Henceforth they roll along the torrent of the circulation, like so much inert dust ; and were it not for the change in color winch they present, nothing external would betray the profound change they have undergone I an analogous alteration in the blood-globules be at lessl tain grave conditions of the organism, when intense . with- out there being pulmonary i In those patients who rapidly succumb in the course of acute art; rheumatism, the blood and t rdium and the synovial sacs often have an acid | who are struck by lightning, anatomy i larerio rigidit itinoea scarcely a moment, and ilmoel immediately rri\ The same thing happens with over-driven ania mena occur, as Brown-Sequard 1 have been i Is it not almost certain that all after death, c o rresp o nd I which aln luring life, but which hitn< I inaooi - tigation ? But I shall not insist npon this point ; I conducted you to a territory which is still almost urn promises abundant harvests in the fir IV. Qentlem actually to exist betwa d p The speculative i sidered here, but rati, us by the cessora ol and Mageiidic While fully r it exhibit* d in th belong to them, the new ph still abfl 1 supernatural intlueiice V dictates, freeing itself from all 1 brought over to proper; this moment one must : 'U be- these two orders of t It purposes to bring all I io workings of cert iratases, property dn well-defined tl It does not b si to find out the cs- rience has proved that the human m mate causes, or the conditions of p] It r. - that, in this the limits of our know" same in biology as in p] a certain point, nat , no longer gives an answer. ther, it mak< - lighten and furnish a solid It brings t I it. in reality. method, that admirable rhich in it so many mysteries. THE DISEASES OF OLD AGE. 13 Thus, M. Claude Bernard, a great teacher in physiology, expresses him- self in various places of his remarkable work, with which you are all ac- quainted, and where, in a profound manner, he discusses the question with which we are here occupied. 1 I shall limit myself to bring forth the express condition which he also imposes upon all legitimate intervention of physiology in the domain of medicine. First, pathological interpretation ; such, says Bernard, is the imprescriptible rule ; to first state the morbid phenomena, and then to en- deavor to explain them from the standpoint of physiology, when this is possible in the actual condition of science. The opposite procedure, which consists in starting from anatomy and physiology, in order to deduce the conditions of the disease, is full of peril and bristling with danger. Let us not be seduced by the elegant view, the ingenious ideas which it can suggest, for experience proves that too often it has led to an imaginary pathology corresponding in nowise to the reality of things. It appears useless for me, gentlemen, to dwell longer upon the innum- erable services already rendered medicine by the intervention of the data of modern physiology."' I wish, h«>\vc\er, to dwell for a moment upon what it is agreed to call experimental pathology. The mutilations to which the physiologist subjects an animal, in order to penetrate the mechanisms of normal actions, are almost always attended with various morbid disturbances which may already become a subject for thought to the physician. But experimentation may apply itself still more directly to the problems which pathology oilers to it. We have really suc- led in creating various morbid conditions in animals, either in causing them to sailer certain mutilations, or in submitting them to the action of poisons, viruses, venoms, putrid materials, etc. The idea of producing, in this manner, artificial diseases, is far from be- ing a new one, and we must go back to Lower, Baglivi, Van Swieten, and Autenrieth, in order to find the first traces of it. But, above all, it is in theso last years, and from the impulse given to it by Magendie, that experimental pathology lias really been constituted and assumed all its scope. The works of Claude Bernard, Longet, Brown-Sequard, Yirchow, Traube, Vul- pian. and many others, are ready to testify what can be attained by this method. Nevertheless, the brilliant results it has already furnished in its short career should not allow us to forget that certain limits seem to be imposed upon it. Experimentation succeeds in producing a temporary glycosuria by the aid of a traumatic lesion. It reproduces marvellously well the various symptoms of thrombosis and embolism. It accelerates or stops at will the movements of the heart. It induces at its pleasure all the symptoms of uraemia. Thanks to certain lesions of the nervous system, it originates pleurisy, pneumonia, and acute pericarditis, more or less com- parable with those observed in man. Recently it succeeded in developing in an animal the phenomena of traumatic fever, by injecting into its blood the liquid of another animal from the surface of a recent wound ; and thus was confirmed an idea promulgated a long time ago by a French surgeon. 1 Introduction a 1' Etude de la Medecine Experimental. Paris, 18G5. Especially consult pp. 117, 119, 125, 127, 140, 330, 343, 347, 348, 358, and 369. 1 Consult, upon this subject, the remarkable discourse delivered by my friend, Dr. Brown-S quard, before the College of Physicians of Ireland, February 3, 1805 : On the Importance of the Application of Physiology to the Practice of Medicine and Sur- gery. In the Dublin Quarterly Review of Med. Sci., May, 1805. 14 CLINICAL LECTURES But those diseases which have a slow process of evolution can he said to escape it most often. Constitutional diseases and diatheses, in particular, seem to cessible to it ; ' and how can it be otherwise if the conditions of d inent of these diseases are those with which the physician 1 unacquainted? Let us D existing in some respects, betf neons and certain slow intoxicati alcoholismus, which h tion of the csorresponding i f which my i produced in the lity. , , _ . • it may I certain d in their i symptoms thereof and always in the regular i late the stm! predisposition, and also enligl morbid conditions. Pinal sons, wl of a truly rational therapeul titlemen, itwould 1 by combining clinical data with pathological histology, and pi arrive al a perfectly ratioi morbid conditio] ob» elusions which must now h '—I think 1 the neo that method which I should : counterpoise ' d But th< to W legitimately ii bed by the intervention ol l and ap] originatea truly rational d Such ia towards which advance along this path with pro premature generalization; that w. ;, rilu l i • of renovation in which ill ask, what is th these grand notional H wsomuchadohadafikvorableinfl more aick cured to-day than in by- This gentlemen, is a no-v indiscrt < t qu ^ Ll « hut too easily turned THE DISEASES OF OLD AGE. 15 with answering, in the words of an honored teacher, that art without science very soon degenerates into routine. 1 Commonplace scepticism, which is so readily opposed to all progress of the human mind, is a convenient pillow for lazy heads ; but in this epoch there is not time to go to sleep. To place in its true light the favorable influence which, in another way, scientific tendencies might exert upon the advancement of medicine, it is sufficient for me to recall to your minds the remarkable transformation which this science has undergone during .the course of the lust twenty years in a neighboring country of ours — in Germany. Let us for a moment cross over to the other side of the frontier, and in thought go back to about the year 1830. At that time Schelling and his daring "Philosophy of Nature" ruled as absolute lords over the German mind. Poetical notions and transcendental conceptions were then the fashion; and a physician even permit ted himself, in a treatise on mucous fevers, to seriously compare a blood-globule with the terrestrial sphere because both were round, flat- tened at the poles, and both poasesai -d a central nucleus surrounded by an atmosphere. 1 During that time medicine wafl reduced to a deplorable condition, al- though the Germane | I translations of the principal works relating to pathology, which hadjusi been published in France or England ; still the ] implished by I it-named countries was for the < mans as though it had never happened, for no one understood the impor- tance of it. Physical diagnosis had never been formulated, either in the hospitals or in private practice. In more than one German university the Btethosoope was almost un- known ; when they accidentally ran a CT O Ofl one of these instruments, they examined it with a sort of infantile curiosity ; or, again, they greeted with istic jests those few eccentric ones who by means of this bit of v. pretended to hear unheard-of things. \\< sides, most of the die t the chest and the heart, and chronic affections of the skin, were an almost un- explored region. Even when they began to take notice of the French, it was only to turn to ridicule, and this time with the appearance of justice, that strange mania which impelled them to consider all diseases as inflammations. ' Things remained in this state until about the year 1840. Then the work of regeneration commenced, chiefly through the influence of Schoen- lein, by the importation of French methods, and their intervention in the domain of the clinic. Then it became the turn of pathological anatomy, brilliantly represented at Vienna by Pokitansky. But Midler had already appeared with his physiology, and soon he created pathological histology, which was to remain tor a long period an almost exclusively German science. Gentlemen, you know the rest. Then the German universities pre- sented the spectacle, new to them, of an almost unheard-of feverish activity ; and you are not ignorant of the fact that that feverish labor, which even now does not show any signs of diminution, has already produced more than one fundamental work. 1 " Practice without incessant scientific renovation would very soon become, be as- sured of it, a belated routine, and one as if stereotyped." Behier : Lecon d'Ouverture du Cours de Clinique Mc-dicale, p. 19. Paris, 1867. - H. Horn : Darstellung des SchleimfK'bors. 2 Auflage. 3 C. A. Wunderlicb: Gcschichte der Medicin, p. 332. Stuttgart, 1859. 16 OLIHICAl LECTURES OH During more than ten years tL. intellectual movement almost unnoticed \>y the French. From time to time some far-ee< server endeavored to attract pabHc attention to it, but he I r.il indiflfi ad while all < - in activir;. 1 with oti we comprehend that a grand that it must be reckoned ami d'outn i and wbi inclined, perl with bug think tli il them alone. We should, | triumph. found thi which hi With the j)clitic:il | abuse tl • a strict patriot i should f such, to do r .•' \\ ilar let m "Reason," says < le world Individuals I - ..o. translated bj Dr. JaccouJ. a 53. 1883. THE DISEASES OF OLD AGE. 17 LECTURE I. GENERAL CHARACTERISTICS OF SENILE PATHOLOGY. Summary — Object of these Lectures — Organization of the SalpetriiTC Hospital from a Medical Point of View — Chronic Affections; Diseases of Old Age — History of Senile Pathology — Physiology of Old Age — Anatomical Chauges in the Organs and Tiseues — A complete RemtmS under the Term Atrophy — Exceptions in the Case of the Heart and Kidneys — The Various Derangements Resulting from these Modifications in Structure — Certain Functions Diminished in Old Age, and Others Preserved — Pathological Immunities of Old Age ; the Peculiar Impress it gives to the Greater Number of Disea Gentlemen : — The lectures which VOU arc going to attend arc meant to bring before you in review i: interesting clinical facts which the Salpetriere Hospital can present to your observation. Those among you, gentlemen, who until now have frequented only the ordinary hospitals, may expect to see pathological I with quite a strongly marked local color You arc, no doubt, acquainted with the internal organization of this itablishment. 1 sing out of consideration the employe^ and also the number of lunatics, idiots, and epileptics, who form a Separate and distinct class, th< mainder of the population of this asylum consists of about twenty-five hun- dred females, who, with some few exceptions, belong to tho least-favored portion of society. From the standpoint of a medical clinic, which alone should engage our attention, they form two very distinct catego: The first is composed of women who are, in general, over seventy years of age — for the administrative statutes have so decided it — but who, in all respects, enjoy an habitual good health, although misery or desertion has put them under the protection of public aid. Mere, gentlemen, is where we shall find the materials which will serve us in making a clinical history of the affections of the senile period of life. The second category comprises women of every age — smitten, for the most part, with chronic, and, by repute, incurable diseases, which have re- duced them to a condition of permanent infirmity. In this respect we here possess advantages which those in the ordinary hospitals are, for the most part, deprived of ; and we are also placed in the most favorable position for studying with benefit those diseases whose evo- lution is a slow one. Indeed, the numerous population of these wards .allows us to observe, 1 Those of our readers who desire more ample details upon the interior arrangements of the Salpotiiere, as well as the history of the institution, can consult with benefit the interesting chapter reserved for The Hospital for the Aged (women), by M. Hus- ton, late Director-General of Public Assistance, in his Etude sur les HJpitaux. Paris. 1883. o 18 CLINICAL LECTURES OX under the most diverse aspects, the principal types of one and the same morbid species ; but, what is still of greater importance we are here per- mitted to follow the patients through a long period of their existence, in- stead of being present only at a single episode of their history Thus we see developed to its utmost limits the pathological process whose initial phase is usually the only one known ; in fact, we are called upon to state the organic lesions which characterize the disease when it has been termi- nated by death. _. . , ^ In other cases -unfortunately but too rare— we see cures effected some- times spontaneously, sometimes induced by the hap; i ution of the art But that which we learn to recognize here bettor than anvwh else, is the value I ached to those means which alleviate when / impossible for us to C Q . To-day I purpose calling your attention more especially tot; eral characteristics of I « hich sin .pon the last period of life. I— The importance of ■ special study oi the diseases of d root be contested atlhis day. We haw pathology of childhood oonni kind and il H is indifl that it should b point of view, then ak «'"*- not be surmount nce with its peculiar characi . , \ml yet gentlemen, ti lectedforalongtime.anci «d mob °^hrTat an' epoch v*r, w> in Y. that the pathology of old allowed the cxpiv^.n, in all scarcclvcitca\vorkinwhichthcsh,h-, particuL physiognomy of the rcatisc of Vlinvr, published in L724 lastly that of Vi>h,r. which da WOT** of the past ccnturv which touch, in a p.nodofhfcSiavcahtcraryoraphil, , ingenious parap] r^reaeVved for K fff.^ SUttlJ ever atthe epoch when h Sxiere Efosptod was already organ which had formerly been part of the institution . the infirmary had been found* the W>td-Dieu at the risk of dying on the v. But IW could not think of rotrainn of science. Much more ambitious lus idea was to embrace pathology hi philosophical nosology by applyin. cordnm to the rather emphatic hu f the eight the ditVerences which separate senile from ordinary j rluvlv I mud described in his writings, although he pass, eater portion of his medical life in hoapil ** the a ,er : IMirina Qenoauioa. iW.iv ■*• «■*>• l ** iel : Trait* de Mod. Ctinique, Inteodootiea, p. am rm THE DISEASES OF OLD AGE. 19 To Landre-Beauvais, one of the scholars and successors to Pinel at the Salpetriere, we owe the first special description which had ever been given of a disease met with at every step in the wards of this hospital, although it is not exclusively a disease of old age. 1 I speak of nodular rheumatism (rheumatisme noueux), called also arthritis pauper um, which is a very frequent disease among the indigent classes. Landre-Beauvais designates it by the name of primitive asthenic gout, while at the same time he recognizes that it differs from true gout. Here, gen- tlemen, is a formidable affection on account of the infirmities which it in- volves ; in every respect it deserves to be put in the first rank of those chronic diseases which prevail in this hospital, and to which, later, we are to devote our attention. The clinical lectures delivered at the Salpetriere by Iiostan, about the year 1830, had immense publicity at that time. Several questions relating to senile pathology underwent a profound study at the hands of that emi- nent professor. 2 Two of his works, above all, remain justly celebrated. The first has for its object to prove that the asthma of the aged is not a nervous disease, but one of the symptoms of an organic lesion ; and to day we know that, although this proposition when taken in its general sense is too absolute, yet it is not the less true in the great majority of cases. The second is a remarkable study upon cerebral softening, which has completely trans- formed all our notions upon the subject. It is known, according toRostan, thai this alteration, which is so frequent at an advanced period of life, far from being the result of inflammatory action, is a senile destruction pre- senting the most striking analogy to the gangrene occurring in old age; and the researches of observers, aided by all the modern means of investi- gation, have abundantly confirmed this idea. The immense amount of material laboriously gathered by Professor ( ruveilhier, during his stay in the Salpetriere, has contributed hi a great measure to the construction of an imperishable monument — I mean the " Atlas of Pathological Anatomy." Innumerable observations, which have shed a new light not only upon the pathology of old age, but also upon the history of many a chronic affection, are found accumulated in this vast work. On account of a more or less direct impulse from the great teachers whom we have just mentioned, several important monographs relating to the diseases of old age have been jmblished by observers who drew the ma- terials for their works from this hospital. I shall only mention the remark- able memoir of Hourmann and Dechambre upon pneumonia in the aged, ! and the treatise on cerebral softening, by Durand-Fardel. But, to constitute in reality a senile pathology, these scattered frag- ments must be brought together in a systematic manner. And such was the end which Prus sought to attain in his "Researches upon the Diseases of Old Age/' presented to the Academy of Medicine in 1840. But, in this direction, the French writer had been preceded by Canstatt, in Germany ; to the latter author we owe the first dogmatic treatise that has appeared upon the diseases of old age. 4 1 Landre-Beauvais : These de Doctorat, an VIII. 2 Memoire snr cette question : L'Asthme des vieillards, est-il une affection nerveuse 1817. Recherches sur un Maladie encore peu connue, qui a requle nom de Ramollis- sement du Cerveau. By L. Rosian, Physician to the Salpetriere. 1820. 3 Archives de Medecine. 1835-3G. 4 Die Krankheiten des hoheren Alters, etc. .Erlangen, 1839. 20 CLINICAL LECTURES OX Unfortunateby, this work, which bears the date of 1839, was comp under the influence of Schelling'e doctrine, which so long reigned ac. the Rhine, and which bears the ambitious title of the "Philosophy Nature." In it imagination occupies an enormous amount of room at the expense of positive and impartial observation. Still, we do find in the work of Canstatt ingenious and often true ideas, which insure him an honorable place in science. An entirely different method inspired the studies of Beau ' and of Gil- lette 5 ' upon the d of old age, as well as Durand-Fardel's M Tl Clinique," published in L864 In addition to these synthetical works, we might cite numerous monographs relating il points on senile thology ; but we do not pretend to name all, and, 1 ill have more than oik tocaaiou to allude to I rks in the course of our lectures. We shall finish this brief historical sketch by mentioning three inter- esting foreign works, recently published, from whicl ntly borrow. Thenrsi 'luminous •■("iini uses of Old Age,*' from the pen of I >r. Geist, PI th< Hosj ital of the Saint Esprit, in Nuremberg, The second is a "Collection of I Ob- servations," written by Dr, M tfa ol ipital for I i. in Frankfort The third is the work of I published in London in lM'.i. II. — There is a common cl tic which is found in all th< I have just named to you : this is a mai possible, the particular points which are distinctive of the diseases i lty to the anatomical or physiolo. I which occur in inism solely on account PI not womhr at this, if 1 that nearly all these writ in aide, \^ the orgai the modifications under di possible light upon the history i^{ diseas. We shall have to noti other t' inges which old age induces in the organism sometum a point t the physiological and the path bj an inn oephble transition, and to he no longer sharply distinguish I shall, then, undertake to .natomy and f iology of the senile condition, but not without always to look upon them fro; I shall limit to the indication of the most general c upon details, it will be only for the purpose of dedue:. to practical medicine from them. Certain general modifications at once arrest our attention. You an familiar with the external appearance of an old man — that skin, those thin and gray Lock mouth, the st rm which is bent upon itself— all ti .. ' r.tmlcs QiniqBM rax 1m ™*1 de Medecine de Beau. Art. ViftlUeBM, in the Supphment M Pietionnaire dca Did ■ Mede- eiiuv Paris. 1861, Goist: Klinik der Greisenkrankhon n. TlllUgaa, 1N>0. Mottenheimer •ir l.ohiv d«X Groisonkrankhc. THE DISEASES OF OLD AGE. 2L of the individual, for, at the same time the stature diminishes, the weight of the body becomes less, as Quctelet has proved. 1 A more or less pronounced emaciation usually corresponds to these various phenomena. However, you may meet with a different state of being — that is, as they used to say, the habitus coi'poris laxus, characterized by an accumulation of fat beneath the integument and deep within the splanchnic cavities. But this is generally a transitory condition, and it is not long before it gives way to the habitus corporis strict us, which is the -almost exclusively prevailing state at the period of decrepitude. That emaciation spoken of is the consequence of a morbid process which exerts its action, not only upon the muscles of organic life and upon the various portions of the skeleton, but also upon the greater number of the splanchnic organs ; the brain, the spinal cord, the nerve-trunks, the lungs, the liver — in fact, all the blood-making organs — participate in this retrograde movement ; the sjDleen and the lymphatic ganglia undergo a re- markable diminution in weight and in volume, which diminution advances with age. But, by a very remarkable kind of contradiction, the physiological rea- son for which does not yet seem to us to be sufficiently established, the heart and the kidneys arc exceptions to this law,*' and preserve the dimen- sions found in middle life. Indeed, in many old people the heart is seen to undergo a genuine hypertrophy ; 3 this, it seems to me, is a pathological condition dependent upon that arterial degeneration which is called senile. On its side the net-work of capillary blood-vessels grows poorer and poorer, not only in the principal viscera, but also in the deep parts of the skin and the mucous membranes. The latter at the same time lose a portion of their villous and glandular elements in the intestinal canal.* Of what does this atrophic action, which exerts its forces upon the col- lective organs and tissues, consist ? First, and in the highest degree, it is a simple process of atrophy ; the cellular elements of the parenchyma, the muscular, and perhaps also the nervous elements, progressively dimmish in volume, but without presenting any essential modification of structure ; this is pre-eminently noticeable, according to Otto Weber,* in the muscles of the aged where the elements are pale, of small dimensions, and all very nearly equal in volume, contnuy to what is the case in adult life. Connec- tive-tissue, however, does not participate to the same degree in this work of slow destruction ; it is even seen to predominate over the specific ele- ments in the viscera ; and this has been well established by Dr. Bastien in the case of the liver and the majority of abdominal organs. But, in a more advanced stage, atrophy is accompanied by a degenera- tive action ; that is, the elements undergo modifications in their chemical constitution, and become the seat of pigmentary or fatty degeneration and calcareous incrustations. This, for example, is what occurs in the cells 1 According to Quctelet (Book II. , chap. ii. ), man attains his maximum weight at about the fortieth year ; he commences to lose weight at about the sixtieth, and at eighty he has lost at least six kilogrammes (thirteen and one- fourth pounds). In women, the maximum weight is attained at fifty. — Sur l'Homme et le Developpement de ses Fa- culties. By A. Quetelet, Perpetual Secretary to the Royal Academy of Brussels. Paris, 1835. 2 Rayer : Maladies des Reins. Vol. i., p. 5. 3 It is hardly necessary to recall here the justly celebrated work of Bizot, inserted in the first volume of the Memoires de la Societe Medicale d'Observation de Paris. 4 Berres, after Geist, loc. cit. N. Guillot : Recherches sur la Membrane Muqueuse •du Canal Intestinal. Jour. l'Expcr. Vol. i., p. 101. 1837-38. 1 Handbuch der allgemeinen und sp. Chirurgie. Vol. i., p. 309. Erlangen, 1865. 22 CLINICAL LECTURES ON of the brain, as we are informed by Professor Vulpian, the perfect exacti- tude of whose statement I have frequently been able to substantiate. 1 According to Virchow, at the same time that the neuroglia tends to pre- dominate over the nervous elements in the encephalon, it habitually becomes infiltrated by a more or less considerable number of amyloid granulations ; ■ the brain-tissue then undergoes a chemical alteration, according to the re- searches of Bibra, which were confirmed by those of Schlossberger. 3 The fatty materials which enter into its constitution suffer a notable diminution, while, on the contrary, the proportion of water and phosphorus is in- creased. And yet, according to Vulpian, 4 fatty granulations are deposited in the primitive muscular fasciculi of animal life, solely because of the progress of age ; and this alteration may attain such a point in the lower limbs, where it especially shows itself, that a more or less complete paraplegia is the result. The muscular fibres of organic life do not escape fatty degeneration, and you will frequently have the opportunity to prove that the muscular wall of the heart is almost always the seat of it in women who die at an ad- vanced age. To this alteration in the cardiac tissue can be ascribed the phenomenon of asystolisni which is so often observed in old people, even when they seem to be in the best of health. Indeed, fatty granulations often fill the walls of the cerebral arterioles as Paget 6 has shown, ami Professor Robin also. 6 And it has been shown by Vulpian that this senile change is not peculiar to man, but that it is equally encountered in old mammals, in the dog especially. No one of you, gentlemen, will fail to observe that when these altera- tions shall have attained quite a pronounced degree, they will go beyond the limits of the physiological state, since they have the power to produce, of themselves, functional derangements which at times are extremely grate. This becomes especially clear concerning that change in the arteries called atheroma, and the calcification which is so frequent an accompaniment of it, From a standpoint of histological development, atheroma of the arteries tends to separate itself widely from the usual forms of senile atrophy. The latter seems to be the result of a purely passive process ; the former, on the other hand, seems, in the first phase of its evolution, to consist in a more or less active proliferation of the elements which are the normal constitu- ents of the internal coat of the artery. At a given time these newly formed elements suffer a fatty degeneration ; but this is a consecutive phenomenon. The granulations which have thus been formed accumulate in the deep portions of the internal lining membrane, and it is in these deeper portions where the process first appears and is most strikingly marked : the most superficial layer becomes distended with them, though it still resi-' quite a long time. In this way are formed those accumulations rich in fat and cholesterin crystals, which have been designated by the name of atheromatous abscesses. They are sometimes seen to open into the cavity of the artery avIiosc walls they occupy ; and their contents, mingled with the blood, may be swept into the general circulatory current, reach ves- 1 Lecona de Fhysiolosrie Generate et Comparee du. Systenie Xerveux. p. 965. Faris, 1866. * J Handbuch der sp. Pathologie. Vol. i. , p. 046. 3 Consult Geist, op. cit., p. 158. 4 Loc. cit. 5 On Fatty Degeneration, etc.: London Med. Gaz. I860. 6 Memoires de la Societe de Biolosrie. Vol. i.. p. o'A. I8t THE DISEASES OF OLD AGE. 23 sels of a small calibre, and then cause those frequently formidable symp- toms of capillary embolism. In a less advanced stage the action of the atheromatous tumor is limited to narrowing, and later on to complete obliteration of the artery which is the seat of the degeneration. Then are produced in various portions of the organism those changes resulting from faulty nutrition, which constitute one of the most original chapters in the pathology of old age. In fact, we see that the majority of the cases of cere- bral softening and capillary apoplexy of the encephalon, occurring at an advanced age, result from atheromatous obliteration of the arteries :* it is the same with visceral infarctions, with that gangrene of the extremities called senile, and with many other changes as well. But here we are encroaching upon the domain of pathology, a thing we wish to avoid for the present. I shall now indicate in a few words those physiological modifications which correspond to the textural changes, the summary view of which has just been presented you. If it is true, in a general way, that with the progress of age all the functions are seen to be- come simultaneously enfeebled, yet it must not be supposed that this propo- sition is always infallible ; and it is only the analytical study of facts that can afford us any reliable information concerning the true state of affairs. The generative mechanism and the muscular force in the aged undergo so evident an enfeeblement that it is not necessary to insist upon this point. 2 And with regard to the functions of the nervous system of organic life, it is enough to recall the well-known lines of Lucretius. Prseterera gigni pariter cum corpore, et una Crescere sentimus, pariterque seuescere mentem. — u De Nat. Rerum," ii., 446. The functions of the respiratory apparatus, as a whole, are equally weak- ened, and we find the expression of it in a diminution in the quantity of carbonic acid exhaled, in an augmentation of the number of inspirations, and in the reduction of the vital capacity of the lungs ; this last result, ac- cording to the spirometrical researches of Wintrich, Schnepf, and Geist, begins to manifest itself about the thirty-fifth year of life, and reaches its maximum between the sixty-fifth and the seventy-fifth. 3 Most of the secretions are diminished, the sweat and the urine in par- ticular ; and it is almost beyond question that the senile dyspepsia, upon which our renowned naturalist, Daubenton, has insisted in his great but lit- tle-known work, depends in great measure upon a sensible diminution of the gastro-intestinal secretions. 4 But what are we to think of the functional weakening of the arterial system, when, according to Dr. Marey, & the heart of the aged is more pow- erful than ever, and the arteries present energetic pulsations ? It seems proved that, in all cases, the pulse augments its frequency in the senile period of life. 6 1 It is to be clearly understood that we do not speak of intra-encephalic hemor- rhages, which have also been rather gratuitously attributed to an atheromatous degen- eration of the cerebral arteries. Later there will be an opportunity for further ex- planation on this point. 2 Consult Empis : Etudes sur FAffaiblissement Musculaire Progressif chez les Vieil- lards. Arch, de Medecine. 1862. 3 Geist: op. cit., p. 102. 4 Memoire sur les Indigestions, qui commencent a etre plus frequentes chez la plupart des Hommes a l'Age de 40 a 45 ans. Paris, 1785. 5 Etudes sur la circulation, p. 415. "' Leurefc et Mitivie : Sur la Frequence du Pouls chez les Alienes. Paris, 1832. 24 CLINICAL LECTUEES ON We are but slightly acquainted with the degree of intensity which nu- trition manifests in the aged ; but the use of the thermometer has given us much more precise ideas with regard to calorification. Before having applied this instrument in researches upon this subject, it was believed that the temperature in old age was lower than in adult life ; but to-day we know that the heat of the central parts remains about the same in all peri- ods of life. It has even been supposed that the general temperature rises toward the end of life. 1 My own researches tend to prove that the only real difference which exists between aged persons and adults in this re- gard, is that in the former the axillary is much lower than the rectal tem- perature, while in the latter there is hardly any perceptible difference be- tween the two. Here is a woman, one hundred and three years old, and who is in excel- lent health ; the axillary temperature is 37.4 ( I 'ahr. ); while in the rectum the temperature is 38° C. (100. -4^ Fain*.), which is the maximum normal temperature in the adult. Thus, gentlemen, if old age enfeebles the greater number of our func- tions, it is far from paralyzing all of them ; and rigorous observation shows us that, in certain respects, the organs of the aged perform their tasks with quite as much energy as those of adults. m. — Gentlemen, the preceding sketch tells as that the progress of age establishes a wide difference in pathological phenomena, by virtue of its physiological modifications. We shall then study this question from three different standpoints : First. — There do exist special diseases of old age which, in part at arise from the general modifications which the economy has undergone. As examples I shall mention senile marasmus, senile osteomalakia. senile atrophy of the brain, certain alterations of the blood, 3 senile asystolisni, and lastly, arterial atheroma, whose study constitutes one of the most in- teresting phases of medicine in old age. >/ul. — Among the diseases which can exist at other periods of life, there are yet several which, during the period of senility, present special characteristics ; such, for example, is lobar (croupous) pneumonia. tL rible enemy of the aged, and one of the principal causes of mortality in this hospital. We shall later on recur to this part of the question. Third. — Old age seems to create, in certain regards, pathological im- munities. The eruptive fevers, typhoid fever, and phthisis, are quite uncom- mon at this period ; still these immunities must not have their importance exaggerated, for they are Car from being absolute, as Bayer has proved in the case of typhoid fever, Murchison in that of typhus, and other authors in cases of other diseases/ And who, besides, does not know that Louis XV. died of small-pox at the age of sixty-five ? ^on Barensprung, in Canstatt's Jahresbericht. 1831; and Geist : op. cit. . p. - The frequency of intravascular coagulations in the aged seeraa to prove that there exists in them a tendency to inopexia. and purpuni miflfi conies under this rule ; for it is probable that this latter affection arises — at least it does so very often— from the spontaneous rupture of the capillary vessels. (Consult Wagner : Manual of Gen Path.. p. o4o, for Inopexia. — L. H. H.) 3 Consult Bayer : Gaz. Med., vol. x.. p. 573, 1842 ; and Uhle : Ueber der Typ: dominalis der alteren Leut., in Archiv fur pbysiol. Heilkunde. Bd. Ill . These authors report striking examples of typhoid fever i: Murchison calls attention to the fact that no age is exempt from typhus : from the fifteenth to the twentieth year the proportion is U> in KHJ ; from the sixtieth to the sixty-fifth, it is 2.0 in 100; from the seventieth to the seventy-fifth, it is 1.21 in 100. The cam THE DISEASES OF OLD AGE. 25 I think enough, has been advanced, gentlemen, to convince you that a senile pathology does exist. And to offer you a striking example of the modification which age may impress on manifestations of disease, we shall study, at our next lecture, the febrile state in old age, and endeavor to point out the analogies and the differences existing between it and the febrile condition in the adult. which occurred at the most advanced age was one in a man of eighty-four. Kelapsing fever is less frequent than typhus in old age, although several examples of it have been observed ; over fifty years the proportion is 6.03 per 100 ; over sixty it is 1 . 6 per 100. Old women are more exposed to these two diseases than are old men. For typhoid fever the proportion is 1.40 per 100 over fifty years ; and 0.5 per 100 over sixty. These figures are enough to show that the relative immunity enjoyed by the aged in respect to the continued fevers is far from being absolute. — A Treatise on Continued Fever in Great Britain, pp 61, 303, and 410. London, 1862. Now, as regards phthisis, Vuipian and myself have noticed that tuberculization is more frequent in the Salpetriere than is generally supposed. One of Vulpian's stu- dents, Mr. Moure ton, in his iaaugural thesis, reports nine cases of acute tuberculosis in the aged. Three of the patients were over eighty, and acute phthisis was primary in all of these c;;ses except one, — These de Paris. 1863. Each year in the Salpetriere we notice some cases of cerebro-spinal meningitis foudroyante. Since 1852 I have gathered quite a number of facts of this kind, which will be found collected in the thesis of Dr. lnglessis. — Sur quelques Cas de Meningite Oerebro spinale observes a la Salpetriere pendant le printemps de 1852. Theses de Paris. 1855. 26 CLINICAL LECTUEES ON LECTUEE II. THE FEBRILE STATE IN THE AGED. Summary. — Want of Reaction in Old Age— Organs seem to Suffer separately— Latent Diseases — The Gravest Lesions may pass Unnoticed — Fever in the Aged — What is Fever? — Importance of the Clinical Thermometer — Chill in Old People — Tem- perature-Curves of Lobar Pneumonia — The Practical Deductions to be made thereform — Defervescence, Crises, and Critical Perturbations — Diseases where the Temperature is Lowered instead of Elevated. Gentlemen : — At the last lecture I endeavored to bring out the particular stamp which old age imprints on all morbid manifestations. I then re- lied principally on the data of physiology ; but to-day we are to pursue this study remaining exclusively on clinical territory. Not only does old age have special immunities and j^athological predis- positions unknown to the adult, but we also see that, in old age, the gen- eral reaction which we commonly meet with in disease has undergone a complete transformation. In this period of life the organs seem, as it were, to become independent of one another ; they suffer separately, and the various lesions to which they may become subject arc scarcely echoed by the economy as a whole. Thus do the gravest disorders manifest them- selves by slightly marked symptoms ; they may even pass unnoticed, and it is in old age that we observe the greatest number of latent diseases. ' This point of view, gentlemen, is so important in practice that it de- serves to be made more conspicuous ; I shall therefore give you some ap- propriate examples of it. Let us lay aside for a moment the study of physical signs, whose im- portance is elsewhere so great in every respect ; let us forget the difficulties which attend auscultation and percussion in old age ; we shall have oc to recur thereto later on. Let us attend only to those phenomena of sympathetic reaction whose absence, often complete, may certainly be tit cause for wonderment. Let us take as an example one of the most frequent affections met with in this hospital. I mean biliary gravel, which commonly induces in adults general phenomena of great intensity. You are acquainted with the for- midable aspect of hepatic colic, which occurs with such an array of terrible symptoms, which, once seen, are never forgotten. Now, you will learn with surprise that in the aged it is often difficult to recognize its symptom diminished are they ; at best we only find a little weight in the right hypo- chondrium, a few attacks of vomiting, slight jaundice, sometimes delirium 1 "In advanced age the organs seem to act and suffer separately — their sphere of activity appears more restricted. . . . One should never forget that in advam M the gravest lesions may coincide with a small number of slight, almost insignificant symptoms," — Grisolle : Traite de la Pneumonic First edition, p. THE DISEASES OF OLD AGE. 2T and cerebral symptoms; and these are more apt to induce error in the di- agnosis than to enlighten us as to the nature of the disease. l If the biliary passages, when distended by the passage of calculi, show such a very slight disposition to induce a general reaction, it is the same in the case of the renal excretory passages, which may suffer tne contact of urinary gravel almost without pain ; and, in this way, the intense pains of nephritic colic are very nearly wholly unknown in old age. In another kind of cases we see diabetes occurring in patients of an ad- vanced age with very different symptoms from those which characterize it in the adult. The urine, often but slightly increased in amount, contains sugar only intermittingly ; ' and thirst, that betraying symptom, which most frequently puts us on the way of the diagnosis, may be wanting com- pletely in the aged with diabetes. Following such a statement of facts, you will learn without astonish- ment that cancer of the stomach 3 and of the liver, as well as pulmonary tuberculosis, 4 may remain in a latent condition during the whole course of their development. Such are surprises which the autopsy very often pre- pares for us. But in lobar (croiqjous) pneumonia, so frequent in this hospital, the al- most complete absence of general signs is, more than anywhere else, most strikingly exemplified. It is enough to quote, in this connection, a passage from the important memoir of Hourmann and Dechambre. 5 " Old women," say these authors,' "do not even complain of malaise ; no one in their dormitories — neither among attendants, house-maids, nor neighbors — notices any change in their condition. They get up, make their beds, walk about, eat as usual, and afterward, feeling a little tired, they totter to their beds and expire. That is what in the Salpetriere is called sudden death. The cadaver is opened, and a large portion of the pulmonary parenchyma is found suppurating." Do not such accounts seem very strange ? Is it not, however, an ac- knowledgment that the laws which, in adult life, govern the relationship between symptoms and lesions, are completely inverted in the aged ? No, indeed ; there is reason for remarking, at once, that these kinds of facts, though they may not be called in question, yet always ought to be consid- ered as exceptional. And besides, they are not altogether uncommon in ordinary pathology. Pneumonia sometimes remains latent in adults, in 1 " In the Salpetriere infirmary few autopsies are made without there being found a greater or smaller number of calculi in the bladder, yet biliary colics are extremely rare in the Salpetriere." — Beau : Etudes surTAppareil Spleno-hepatique. Arch.de Med., p. 401. April, 1851. " . . . . The fact holds good for colic with all its train of painful symptoms ; but you must take into account the diminution of sensibility ; and it is not rare to find dull pains in the gastro-hepatic region, pains which the patients always ascribe to imaginary causes, but which may certainly have been caused by the presence of calculi." — Gil- lette : article cited, p. 898. I wholly agree with Gillette in this respect, and I may add from personal observa- vation that the dull pains may also coincide with the passage of urinary gravel, and this much oftener in the old than in adults. - Bence- Jones on Intermitting Diabetes, and on Diabetes of Old Age : Medico- Chirur. Trans., vol. xxxvi. 1853. 3 " It is in the aged that we discover those degenerations of the stomach which have a deceptive progress, which are accompanied neither by vomiting, violent pains, nor by dyspepsia— at least the subjects thereof avow not." — Gillette : loc. cit., p. SOS. 4 " Phthisis in the aged is notable on account of its latent and insidious form." — Gillette : loc. cit., p. 898. 5 Archives de Medecine, vol. xii., p. 57. 1836. 28 CLINICAL LECTURES ON certain particular conditions of the organism, especially in drunkards. One can compare several other grave affections with this same type ; for example, who does not know that hemorrhagic small-pox may assume, at the outset, favorable appearances, only to be abruptly contradicted by a fatal termination ? But it is, above all, in the class of infectious and con- tagious fevers that we can affirm facts analogous to these. Thus, in epi- demic yellow fever, in the plague, and in typhus fever, there are cases where the great damage to the organism reveals itself by no symptom which in any way predicts the gravity of the disease. Here the pulse is normal, or not far from it ; the tongue is clean ; the skin is cool, or but slightly warm in the region of the stomach and liver ; the mind is cheerful, and the bodily forces unimpaired. But suddenly attacks of black vomiting set in, and death unexpectedly supervenes. An American physician, Dr. Caldwell, to whom we are indebted for a fine treatise on yellow fever, applies the name wallcing cases to those insidious forms in which the unfortunates, believing themselves scarcely unwell, and continuing to carry on their business to the last moment of their existence, have been suddenly struck down by death. 1 These insidious forms, then, do not exclusively belong to senile pathol- ogy ; but, if we leave aside these few infrequent cases, and regard only the ordinary clinical ones, we are led to recognize the fact thai eneral rule, there is a want of con*elation in old age between the local lesion and the exhibition of general symptoms. A similar state of affairs exists in childhood, as Gillette has ingeniously pointed out to us, J but there it is just the reverse. In that period reaction is, as it were, exaggerated and tumultuous, and a violent derangement of the functions is very far from proving a serious danger. In old age, on the contrary, the organism re- mains impassible, so to speak, in the face of the gravest changes. Reaction is here, then, defective, even to the extent of total absence ; and hen- physician ought to be doubly attentive to. and appreciative of the slightest symptoms, unless he wishes to be surprised by completely unforeseen oc- currences. 9 It is now time to leave this very general standpoint we have just taken, and to broach at last the question which ought specially to claim our atten- tion to-day. We wish to study the febrile state in the aged, comparing it with that of the child and the adult ; and, in order to give more precision to the ideas we desire to set forth, we shall choose, as the type therefor, lobar pneumonia — that disease which is febrile in the highest degree, and is common to all ages of life. Its development will enable us to state the deviations which age may induce in one of the chief symptoms of the ma- jority of acute diseases. " Fever/' says Gillette," in a passage where he echoes the opinion of all 'Med. and Phvs. Mem., containing a Particular Inquiry into the Origin and Na- ture of the Late Pestilential Epidemics of the United States. Philadelphia. 1801 *Loc. cit., p. 873. 3 It must also be remembered that, in old age. sympathetic phenomena sometimes assume an entirely unusual aspect. Thus, pneumonia may assume a masked form, and at one time appear as cerebral apoplexy, with complete resolution and coma, and at another under the guise of a true hemiplegia, with or without contraction of the paralyzed limbs. I particularly emphasize these pneumonic hemiplegia*, of which Yul- pian and myself have met several examples. They always terminate fatally, and we have been able to convince ourselves that there is no corresponding encephalic change. In children, pneumonia may present a cerebral variety characterized by eclampsia or coma. *Loc. cit, p. 874. THE DISEASES OF OLD AGE. 2£ the professional writers who had preceded him — " fever in the aged is char- acterized by an acceleration of pulse and a dryness of the skin, without there being any sensible increase in temperature." He next calls attention to the fact that the initial chill is scarcely noticeable, or is wholly wanting, and that it is the same with the sweatings. The other accessory phenom- ena of the febrile state are, according to the same author, all more or less extensively modified ; and finally, the description which he gives offers a striking contrast to what, in other periods of life, constitute the appurte- nances of the febrile condition. Is it an exact picture, and does it faithfully represent the truth ? We must acknowledge that it does not absolutely satisfy us ; but, in order to justify our restrictions, it becomes necessary to enter into a preliminary discussion. What is fever ? What is meant by the febrile state ? It is hardly necessary to premise, gentlemen, that the definition we seek is in all respects descriptive, and that we make no pretensions to pen- etrate the ultimate nature of the phenomena we wish to characterize. In the days of Hippocrates, at a time when they did not practise the examination of the pulse, elevation of temperature was the one and only element of fever. Galen's definition is sufficient testimony on that point : color prceter naturam, this was the characteristic of the febrile state for that great physician. 1 During a long series of ages tradition has respected Galen's opinion ; but in time it changed, and we see Boerhaave, under the influence of the iatro-mechanical ideas prevailing in his day, declaring that "acceleration of the pulse is the only symptom which we always find present in fever from beginning to end, and which alone is sufficient for the physi- cian to recognize the presence of fever." 2 Since then the question has been taken up many times, and settled in many and various ways ; but it must certainly be acknowledged that to-day the unanimous testimony of modern study has pronounced in favor of the opinion accepted by antiquity. On all sides it has been recognized and proclaimed that a rise in animal heat is certainly the fundamental event of the febrile state. Among the other phenomena that accompany it there is none, not even the accelera- tion of the pulse, which appears in such a constant, such an obligatory man- ner. Fever does not exist when the temperature remains at the normal point, and the pulse may attain the limits of utmost frequency, and still no fever may be present. It is sufficient to mention the extreme and excessive excitement of the circulatory system noticed in certain cases of arterial pulsation, and particularly in the exophthalmic and hysterical cachexia. 3 Now, can it be said, on the other hand, that fever occurs every time the temperature rises ? That is a point on which it is scarcely possible to give an opinion to-day. We really observe, however, an elevation in bodily heat in those cases which seem foreign to all pyretic reaction : in tetanus, in attacks of epilepsy, and in cholera especially at the moment of death ; the temperature may then reach 107^-° Fahr. or 109^° Fahr. But there is, no doubt, some element which escapes us ; it is always the increase in animal heat which predominates in fever, and it may, in many instances, serve to measure its intensity. 1 De different, febrium, cap. i. De g-enerali febrium divisione. There is another definition of Galen's, in which the frequency of the pulse is adduced ; but it occurs in a less authentic work. ' l Aphorism 570. 3 Briquet : Traite de l'Hysterie, p. 326. 30 CLINICAL LECTUEES ON It is the methodical use of a means of investigation unknown to the an- cients which has, in great measure, contributed to definitely fix our ideas on this question — I refer to the clinical thermometer. Though criticism has not spared it, this means of investigation has made its way in our times, and we can foresee that the period is not far distant when its general use shall have spread throughout the ordinary clinic. It is said that the celebrated Swammerdam, of Holland, was the first, in the seventeenth century, to think of appreciating by means of the thermom- eter the heat of disease. 1 Since that time several physicians have engaged in similar methods of observation. In 1754 de Haen called the attention of his students to the necessity of substituting the use of the thermometer for the application of the hand in determining the bodily temperature. And to him also we owe the establishing of an important fact — to which we shall very often allude, because it is so frequently observed in the clinic in old men — that, at the very moment when the skin of the fever-patient is pallid, purple, and cold (pdle, vioiacee et refroidie), in consequence of the contrac- tion of the superficial capillar}' vessels, the temperature of the blood rises several degrees higher than the normal standard ; and that this is not a transient rise, such as occurs in the initial chill of fever, but is, as it ap- pears, a permanent one during the whole duration of the febrile state. In the past century John Hunter was almost the only author who re- sponded to this call. But in our time the labors of Professor Gavarret (1839), of Bouillard, Monneret, and some other French physicians, have enabled us to appreciate all the clinical import of this means of iim tion. Still it is only during the last few years, and in Germany, that any ac- tual progress has been realized in this respect. It maybe asserted without any exaggeration, that, in the hands of Burensprung, Traube, Michael, and Wunderlich pre-eminently, clinical thermometry has undergone a radical transformation. The question is no longer, indeed, to ascertain that the temperature has risen a few degrees in fever, nor to note its intensity ac- cording to the morbid species. The phenomenon must be followed day by day — hour by hour, so to speak — from its very commencement to its definite termination, and in all the varied phases of its evolution, in order i cognizance of its slightest oscillations, and to show that the graphic tra- cings obtained by this methodical investigation give constant types for every form of disease, with variations which correspond to the most important circumstances attending the malady. For this is the only way by which one can prove that these tracings have a real clinical importance, or that they enable us to follow the course of the morbid process better, perhaps, than any other method does, and to recognize its various tq thereby, as a consequence, unquestionably furnishing valuable information pertaining as much to the diagnosis as to the prognosis. Finally, it must be shown that the thermometries! curves are modified according to certain rules and certain laws, either as the disease has been left to itself, or has been treated by the methodical exhibition of this or that medicinal agent ; for we may be allowed to hope that therapeutical experiments may find a criterion of almost mathematical precision in the application of this method. And this is the complex task imposed upon themselves by the authors we have just mentioned ; and though they may not have attained the end proposed, it would be rank injustice not to acknowledge that they 1. least disseminated many truths along their route. The need of similar work seems at last to be understood in Fran Kequin. vol. L, p. 91. THE DISEASES OF OLD AGE. 31 well as in England, and many physicians of both these countries are en- gaged in this line of investigation. 1 For nearly three years we have endeavored, as often as has been possi- ble, to make those clinical observations we have been speaking of, upon the aged patients placed under our charge in this hospital ; for up to that time the practice of thermometry had generally been confined to children and adults. The results obtained will enable me to present you with a few brief considerations upon the modification which temperature undergoes, in the senile period of life, during the different phases of development of the febrile state, and thus to compare this time of life with the other epochs. But I am most anxious to have you observe all the advantages which accrue from thermometry in the clinic of the aged. It is hardly necessary to repeat here that our descriptions will apply chiefly to the fever that ac- companies lobar pneumonia, though several allusions will be made to other forms of the febrile state. I. — Old people seldom have a chill, says Beau, 2 and we have seen that Gillette gives very nearly the same opinion. This proposition is much too absolute ; for more than once have we witnessed violent and pro- longed chills in the aged at the commencement of pneumonia, erysipelas, or synocha 3 {continued fever), a very common disease at the Salpetriere at certain times of the year. These chills, characterized by convulsive trembling, cyanosis, and algidity of the extremities, appear with even a still greater intensity in the paroxysms of symptomatic intermittent fever, which so often accompanies deep-seated suppuration, attacks of visceral phlebitis, and those inflammations of the biliary passages which in old age are so readily induced by the presence of hepatic calculi. 4 And still, in the midst of all these phenomena, at the very moment when the external surface of the body preserves all the marks of consider- able coldness, the central heat is maintained at a very elevated degree. The axillary temperature, it is true, does not enable us to discover all the intensity of this reaction, 5 but in the rectum the temperature runs up to 104° or 105.8° Fahr., as I myself have noticed on many occasions. This rapid rise in temperature in the beginning of diseases very closely corresponds to what is observed in the case of adults, and, in this one re- spect at least, old age yields nothing to youth. But this rapidity of inva- 1 Consult, in this connection, the excellent theses of Messrs. Maurice (Paris, 1855), Spielman (Strasburg, 1850), Hardy (Paris, 1859), and Duclos (Paris, 1864). In Eng- land, Sidney Ringer has made important investigations, and these will be found de- scribed in Aitken's work. 2 Etudes Cliniques sur les Maladies des Vieillards : Journal de Beau, p. 292. 1843. 3 Relapsing fever, according to Tanner and Reynolds. — L. H. H. 4 If hepatic colics are rare in advanced life, it is, on the other hand, very common to see suppuration of the biliary passages caused by calculi, and above all by intra- hepatic gravel. This lesion evinces itself externally by an intermittent symptomatic fever, in which the beginning of each paroxysm is marked by an intense chill ; in the intervals the thermometer often shows the existence of complete apyrexia. Death almost always results from such an occurrence as this. Cornil, in the Memoires de la Societe de Biologie (1865), has published several cases of this kind which were gathered in my service. It is well known that Monneret had already described the existence of a fever of the remittent or intermittent type occurring in diseases of the liver. — Archives de Med., 1861. 5 In such cases there almost always exists a difference of a fraction of a degree, sometimes even a whole degree, between the axillary and the rectal temperature. 32 CLINICAL LECTUEES ON sion is met with only in certain diseases ; there are others where the febrile temperature is reached slowly and gradually ; and to remain within the confines of senile pathology, we shall quote as examples, broncho-pneumo- nia and mucous fever. 1 Besides, it is rare to find the temperature rising to the same degree in these last-named diseases as in lobar pneumonia (croupous p.), a fact we shall have frequent occasion to verify. And now, gentlemen, let us see what are the characteristics of general reaction in that phlegmasia which we have chosen for the type of febrile affections of old age. II. — A chill is the initial symptom of the disease, which from that mo- ment undergoes a regular development. This is the time when it becomes interesting to watch, with scrupulous attention, the daily progress, and, by means of the thermometer, to ascertain the smallest variations in the ani- mal heat ; for, in the majority of cases, they correspond with the greatest exactitude to the various phases of the affection. A momentary improvement habitually follows the initiatory chill ; the temperature sometimes falls more than a degree and a half, and the patient experiences a comparative amount of comfort. But this is a deceptive lull, and that very evening, or the next morning, the disease proceeds on its course. The temperature rises again and reaches 104 Fahr.; and when it keeps at this point for several days, you are justified in believing you have a severe case to deal with ; but when, on the other hand, it tends to fall progressively to 102 Fahr., or even a little below this, the prognosis is, relatively speaking, favorable. The figures I have just given you cor- respond to the evening temperature, for fever in pneumonia (even lobar pneumonia), does not follow a continual, sharply defined course ; there are daily remissions which, in the morning, show a thermometries difference of nine-tenths of a degree Fahr., on an average. But in catarrhal pneu- monia these variations are very much more strongly marked : tin - shown by runs of a degree and a half Fahr., two degrees and a half Fahr., and even more than this in some instances. Now, if you remember at the same time that in this latter disease (lobular j>.) the temperature rises slowly, by successive steps, and scarcely ever reaches the height which we notice in lobar pneumonia, you will readily comprehend that an inspection of the thermometric tracings may often, alone, enable us to distinguish be- tween these two diseases, whose differential diagnosis is at times quite dif- ficult. We have submitted for your inspection a few examples of this kind, several of which were taken in our wards. A simple glance at them is enough to grasp the differences we have been endeavoring to make mani- fest. The juxtaposition of these temperature-curves will enable you to com- pare at the same time the tracings obtained from the child and the adult, in cither the croupous or the catarrhal form of pneumonia, with those taken from an aged patient. A rapid glance suffices to show the perfect analogy between them. 8 Among the tracings which we have before us, there are two which are intended to bring out in relief the influence exerted upon the v.u-iati. 1 Catarrhal or mucous fever ; sometimes synonymous with catarrhal pneumonia. — L. II. II. 2 Touching pneumonia in children, we have borrowed the thennomctrical tracings from the work of Hugo Ziemssen — Pneumonic des Iliadesalter. Bex THE DISEASES OP OLD AGE. 33 -A -A Z-Jh-A 'EOS , v-ntv- I t 1r V 104° F. 102V 6 ° F. 100%° F. 983/ 5 ° F. Fig. 1.— Catarrhal pneumonia in a child. Re- covery. (Ziemssen.) Days. 1 2 3 4 5 fi 7 8 9 105 4 / 5 ° F. A A A A 102V5 F. \ } ^ /i A v V v 1/ s* V V V 98%° F. Fig. 2.— Catarrhal pneumonia in a woman eighty- three years old. Death. (Charcot.) Days. 3456 78 9 10 11 Days. 1 23 4 5 "6 78 105«/s° F. 104° F. 102V 5 ° F. 100V F. 98 3 / 5 ° F. 96V 6 ° F. ^ A A %$t V VI T 4 d 3 ^^= V N. * 104° F. 102V 5 ° F. 100%° F. 98V 5 ° F. • -*-.-£>£-*- AT 2V w- -^ Sl *\ s s Fig. 3.— Lobar pneumonia in a child three years old. Fig. 4.— Lobar pneumonia in a man thirty-eight Recovery. (Ziemssen.) years old. Recovery. (Wunderlich, quoted by Aitken.) Days. 1 2 3 4 5 6 7 8 9 10 11 105V 5 ° F. A ' 104° F. / V-. ) 102V 5 ° F. J ^ \ t 100 2 / 5 ° F. \ V A 98 3 / 5 ° F. V \ — n 1 Fig. 5. — Lobar pneumonia in a woman seventy-five years old. Recovery. (Charcot. 1 ) 1 In the temperature curve bearing Centigrade degrees, 39° has been, I think, accidentally omitted, and 3° written instead. I have ventured to make this correction. — L. H. H. 3 34 CLINICAL LECTURES ON Days. 104° F. 102y 5 ° P. 100V F. 98%° F. 97 7 /io° F- 4 5 6 7 9 10 11 12 13 A 1 !\ fS "l \, '\\ 1 !•• V \ I i \ r "f J k J V J V z a Fig. 6.— Lobar pneumonia, treated by dijritali«. in a woman seventy-one years old. Death. (Charcot.) temperature by therax^eutic agents. In the first of these two drawings (Fig. 6), you see that the administration of large doses of digitalis resulted, on two different occasions when an exacerbation occurred, in a marked fall in temperature. This phenome- non, which never *p ontaneous fy occurs at this period of the disease, can equally well be induced by tartar emetic or by bloodletting. But such a defervescence is too often but a temporary one, and every time the administration of the medicine is arrested, you ob- serve the temperature rise again. The second drawing (Fig. 7) shows the effect of administering rum in draughts of 120 grammes to the dose (3| ounces). During the first stage of the disease you see the t. ore fall slowly but progressively under the in- fluence of this treatment, only to s soon as it is discontinued; the disease then assumes its natu- ral career and ends in recovery. But this is a subject to which, no doubt, we shall recur, and dwell upon at greater length in the course of our meetings. The persistence of a high temperature without well-marked daily varia- tions, and its continuance for a certain number of days, constitute important clinical characteristics of lobar pneumonia, especially in fteaemZffj life. We could mention several affections, which, in the 'adult, partake of this character (the eruptive fevers and exanthe- matous typhus, for example). But in old people we shall rarely find it elsewhere than in erysipelas, if we are to rely on what we observe here in the Salpetriere. Thus you see that the clinical importance of this fact cannot be exaggerated, es- pecially when you remember the difficulties habitually op- posed in old age to auscultation of the chest. And really, a diagnosis of pulmonary inflam- mation is oftentimes made by the thermometer, quite a while before the ear has been able to obtain the signs which evidence th> ease, by means of a stethoscopic examination. 104= F. 102V 6 ° f. 1K.-V F. 08%* F. 96«/ 6 ° F. I A 1 • - ■-, 1 1 \j 1 V s , ■ 1 h , ^_ 1 1 \ 1 u -* y 1 1 1 1 ; * Fig. -Lobar pneumonia in a woman eeventy-rix y« treated with nun. Recovery. (Charcot.) HI. — It remains for us io describe the minute details which l thermo- metrical investigation affords in the period of decline of the febri THE DISEASES OF OLD AGE. 35 the aged, or, as they say in Germany, during the defervescence. Sometimes the fall in temperature which marks the return of the normal state is effected by successive steps during a period of three or four days, as occurs in mucous fever or broncho-pneumonia ; sometimes, on the contrary, it oc- curs very rapidly, and in the course of twelve, twenty -four, thirty-six, or forty-eight hours, the temperature falls two or three and a half degrees, Fahr., or even more than this. At least this is the natural course of affairs in lobar pneumonia, when the issue is to be a favorable one. This rapid fall of the fever is often preceded by a rapid elevation of temperature, which is accompanied by a more or less pronounced and often alarming exacerba- tion of the symptoms. This is what used to be called the critical perturba- tion. We shall, finally, notice that in defervescence the temperature some- times falls below the normal standard, remains so for several hours, in some cases during an entire day, afterward to assume definitely the standard which corresponds to the state of perfect health. They have then gone be- yond the mark, if one may say so ; but only in rare cases have we seen this fall of temperature below the normal limits accompanied, in the case of the aged, by more or less alarming signs of collapse, which in less advanced years quite often distinguish it. In many subjects defervescence is the signal for critical phenomena which are to decide the disease ; these phenomena occur either just at the moment when the temperature falls, or a little later on ; but the latter is move frequently the case. (See Fig. 10. *) In this respect there is no real difference between old people and adults ; except that the sweating-crises, which are so frequent in the mid- dle period of life, are not very often observed in old age, whereas critical diarrhoea, on the other hand, is quite a common occurrence. You can follow the thermometrical tracings (Figs. 1 to 7), which show defervescence in the child, the adult, and the aged, and recognize very readily that its phenomena are subject to identical laws in all periods of life. Up to this point we have only taken into consideration those cases which terminate in recovery ; but when the disease is to take a fatal turn, the temperature, which up to this time has maintained the ordinary limits, rises suddenly, within a day, or only within a few hours, one and a half or even three and a half degrees Fahr. higher. Under these circumstances, in adult life, death usually supervenes- in cases of lobar pneumonia, and the same result follows in old age in the vast majority of cases. But in the latter we observe, quite often, a mode of termination which is the ex- ception in middle life : instead of rising, the temperature progressively falls for two or three days, until it reaches 100.4°, or even 99.5° Fahr., at the moment of fatal termination. And defervescence to this ominous standard is observed not only in those cases where the patient has been counter- stimulated, but also in those where the disease has been left to itself. The four following figures (8, 9, 10 and 11) exhibit the thermometrical tracings of two cases of pneumonia which terminated fatally with an eleva- tion of temperature, and one case in which recovery followed. The fourth (Fig. 11) is a case where death occurred in the defervescence. All the tracings were made here in the Salpetriere. Gentlemen, I have shown you, I believe, all the importance of clinical 1 Consult, in this connection, [the work of Traube : Ueber Krisen und kritische Tage. Berlin, 1852. 36 CLINICAL LECTURES OX thermometry in the study of diseases of old age, arid the utility of the re- sults to which it leads, from the triple standpoint of diagnosis, prognosis, and treatment. But what I am most anxious to prove to you is that febrile phenomena, observed at the most widely separated periods of life, Days. 12 3 4 5 105«/ 5 ° F, 104' F. Days. 105 ing gout — "goutte mat placie") ; and sometimes, on the other hand, form- ing, by a slow, progressive, and, as it were, latent development, those deep organic lesions so often met with in individuals subject to gout (albumi- nous nephritis and fatty heart). Thus, gentlemen, all that old nomenclature, bristling with Santas terms, which the ancients applied to gout — all is unquestionably founded upon clinical observation ; in the rigorous study of facts we shall d> apparent, regular gout ; and irregular gout as masked, retrocedent, mis- placed, etc. It would, no doubt, be useful to institute a reform in this language, which has now grown very obsolete ; but we do not yet feel our- selves warranted in doing it, and so we must, perforce, continue to make use of the terms in vogue among the ancients, while we reserve our privi- lege to interpret their exact sense. For this reason, gentlemen, you will hear us speak of acute and cA gout. Now r , gout is an essentially chronic affection, and can never be acute : still, these two names correspond to two of the principal phases of the dis- ease. Thus, a gouty patient will, at first, suffer from articular attacks, exhib- iting all the appearances of an acute affection, which return periodically at more or less regular intervals. They may be limited to ■ small number of articulations, and more especially to the great toe ; it is then aein gout. In acute genera! gout, which offers a great resemblance to rheuma- tism, all the articulations may be attacked, even the great ones ; tl... example, it is often seen at the same time in the knees, the ellxm - the wrists. THE DISEASES OF OLD AGE. 41 In the interval between the attacks, other affections which depend upon the gouty diathesis may make their appearance ; such, for example, is the dyspepsia which so often torments the gouty ; and such also is gravel, which, in certain individuals, manifests itself as alternating with the attacks of gout. Quite frequently, during a paroxysm of acute gout, we notice the pro- duction of functional derangements, which may be attributed to retroces- sion of the disease ; but visceral affections, which are connected with appre- ciable material lesions, are, on the contrary, very rare. Chronic gout, which may supervene from the onset, only comes, in general, after several attacks of acute gout. The patient who used to en- joy long intervals of repose, sees the attacks becoming more and more numerous during the year, and coming nearer and nearer together. Their number increases without any diminution of the duration ; and, in the end, they meet, they become superimposed — become, after a fashion, sub- intrant, to make use of a term borrowed from the history of paludal fevers ; ! indeed, the patient is the prey of almost continuous pain, with alternate exacerbations and remissions. Corresponding to these permanent symptoms are permanent lesions, which are, at first, in the joints, and afterward occur in the internal organs ; and it is in chronic gout pre-eminently that we find those grave visceral affections which, in general, are the direct causes of death. Besides, when the disease is prolonged, we finally see that cachectic condition superven- ing which ordinarily terminates all great constitutional affections. Then do dropsy, anaemia, and marasmus develop ; and then it is that the patient sinks into an almost complete state of atony — when nature seems no longer to answer to the therapeutic measures which are exhibited to oppose the progress of the disease. Having stated these preliminary ideas on the subject, we shall enter di- rectly upon the history of gout, commencing with the study of those ana- tomical alterations which are its necessary attendants ; and since, in this general disease, the blood-condition seems to be the all-controlling element, we shall first invite your attention to that most important topic. Pathological Blood-conditions of Gout. Since the time when Scheele discovered lithic acid, which we to-day call nric acid, many authorities have thought that this principle might develop, during the course of gout, in the fluids of the economy. Wollaston was the first to prove that gouty concretions were composed of alkaline urates ; and since then Forbes-Murray and Holland in England, Jahn in Germany, and Kayer and Cruveilhier in France, have expressed the opinion that in gout the blood must contain uric acid. But the honor of furnishing the positive demonstration of this fact belongs to Garrod." Normally there exist traces of uric acid in the blood ; but during an at- tack of gout the blood may contain 0.05 gramme to 0.17 gramme of it in 1,000 grammes — ( 20 ooo to -g-oVo). But, to make manifest this proportion, it is necessary to have recourse to very delicate chemical manipulations, which are beyond the domain of the clinic. 1 4 ' Febris subintrans " — a fever where paroxysms succeed one another without in- termissions. — L. H. H. - Medico-Chirurgical Transactions, 1848. 42 CLINICAL LECTURES ON There is a simple process, one whose application is much easier, which, though not indicating precisely the quantity of uric acid in the blood, enables us to establish its presence therein. Put about five grammes of serum in a clock-glass (not in a watch-glass, inasmuch as its curvature is too marked), add a few drops of acetic acid, and then put in a piece of thread. Allow the liquid to remain in a dry place frorn thirty-six to forty- eight hours ; then by the aid of the microscope you can determine the pres- ence of rhomboidal crystals, which encrust the thread immersed in the liquid. These crystals are composed of uric acid. In order to obtain this result, certain precautions must be observed- First, care must be taken that the serum is fresh, for the presence of albu- minoid matter develops a sort of fermentation in it ; the uric acid then de- composing into oxalic acid, urea, and allantoin, just as in the presence of puce oxide of lead. ' Too much drying of the serum must also be avoided, since in that case crystals of ammonia and magnesia phosphate would form and appeal' as very beautiful vegetations. But, as this is quite a soluble salt, it is suffi- cient to add a little water to the preparation in order to dissolve it ; and then masses of rhomboidal crystals, composed entirely of uric acid, will be seen making their appearance. This process, though not sensitive enough to indicate the trace of uric acid which exists normally in the blood, is yet amply sufficient for all prac- tical needs ; in reality it reveals the presence of mdtk part of uric aeid in the blood (Garrod). "When blood is not at your disposal, it may be replaced by the serosity of a blister, which will give the same reactions, provided care has been taken not to apply this revulsive at any place invaded by the gouty innam- mation ; for all phlogistic action causes uric acid to disappear. It is very easy to understand the clinical importance of this process many cases it is an excellent means of di.;_ It also enables us t cover under what circumstances an excess of uric acid is produced in the blood. This phenomenon exists permanently in cases of chronic gout ; but its intensity is augmented during a paroxysm, to fall thereafter below the limits previously marking it. In acute gout it does not occur in the inter- val between the attacks, at least at the commencement of the dis< rod),* but manifests itself anew some time before the onset of the attack. Lastly, in cases of ab-articular gout, we notice the appearance of various symptoms which seem to be connected with the same condition of affairs, since analysis reveals the presence of uric acid in the blood. Now, on the contrary, acute articular rheumatism (Garrod), or chronic rheumatism (Charcot), is never connected with that particular dya and here we find a useful element of diagnosis in doubtful ince it then is quite sufficient to apply a blister to the patient or draw a few grammes of blood from him, in order to feel assured whether it is to gout or rather to rheumatism that the observed phenomena should be ascribed. However, this excess of uric acid must not be considered as a pathogno- monic symptom of the gouty diathesis ; such a phenomenon occurs in Bright's disease and in cases of lead-poisoning. It is. nevertheless, prob- able that this particular condition induces a predisposition to gout : at least it seems to explain the frequency of this affection in the lead-workers of London (Garrod). 1 I\toe oxide : per- or binoxido. 1 See Reynolds : A System of Medicine. Ani London. THE DISEASES OF OLD AGE. 43 The presence of uric acid in the humors of the gouty is likewise re- vealed by the composition of various fluids, either normal or pathological. I have found it in the cerebro-rachidian fluid, and Garrod met with it in the serous effusions into the pleural and pericardial sacs. It is not known with certainty whether it exists in the intestinal secretions, but it is found in the pustular liquid of eczema (Golding Bird), and in the white, powdery substance which sometimes forms upon the skin of gouty patients ; this powder is composed essentially of urate of soda (Petit, O. Henry). 1 In every case it is very certain that sweat, whether spontaneous or induced, does not contain a trace of it (Garrod, De Martini, Ubaldini). 2 "We have yet to ask ourselves the question whether, in gout, the blood does not also present other alterations in its chemical constitution. Al- though this part of the subject is still quite obscure, it nevertheless seems to have been established : First. — That the proportion of blood- globules is maintained at the normal standard in gout, thus evidently contrasting with rheumatic anaemia ; while in chronic gout there is, in the long run, a diminution of the globules — this is gouty ansemia. Second. — That in acute gout there is augmentation in the fibrin ; the bleedings at least, are bufty. Third. — That in chronic gout the albumen of the blood diminishes if there be a diseased condition of the kidneys, in which case an excess of urea will be discovered. Fourth. — That the alkalinity of the blood is always diminished, and this it is which seems to favor the production and deposition of concretions. Fifth. — Lastly, that sometimes the blood contains traces of oxalic acid. As a complemental part of this study we should examine into the state of the urine in gout ; for the question is, whether uric acid is found there- in in a much greater proportion than usual, as has been claimed ; or whether, on the other hand, it is in much smaller quantity, as careful modern investigations seem to have demonstrated. In order to obtain a reliable solution of this question, it is not only necessary to estimate the proportional quantity of uric acid contained in one specimen of urine, but to find out the total amount of uric acid elimi- nated by the kidneys in the interval of twenty-four hours, and this, not only during a single day, but for several days, inasmuch as the excretion of uric acid by the kidneys is intermittent. It is absolutely necessary, then, to have recourse here to a methodical analysis ; and one ought to remember that the presence of a free acid in the urine, or in a specimen where there is not an abundance of the watery part of this fluid, will be accompanied by the formation of those sediments to which generally such an exaggerated degree of importance is attached. It is after having directed attention to all these sources of error that Garrod arrives at the following results : In acute gout, during the fit or paroxysm, the urine is scanty and dark in color, but the quantity of uric acid excreted in twenty-four hours is al- most always considerably less than in the normal state of affairs (0.25 gr. instead of 0.50 gr.). There is, thus, a diminution in the excretion of this product coincident with an augmentation of its proportion in the blood. In the interval between the attacks, the urine was not examined ; still, we shall find that gravel is frequent, as likewise are the crystallized de- 1 Journal de Pharmacie. October, 1841. 2 Union Medicale, No. 40, p. 24. April, 1860. 44 CLINICAL LECTURES ON posits of uric acid formed before micturition (Rayer); but the occurrence of this phenomenon is not sufficient to prove that there is an actual excess of uric acid, either in the blood or in the urinary excretions. In chronic gout the tendency to diminution increases more and more. During an attack the urine is pale, and copious in amount ; so long as the disease remains apyretic, it does not form sediments upon being cooled, and merely traces of uric acid are found in it. Still, from time to time there are unloadings (decharges), during which the urine contains a con- siderably greater quantity of this product. In the intervals between the attacks these characteristics persist : albu- minuria is frequently observed, and sometimes the urine contains fibrinous cylinders. To sum uj), gentlemen, it is clear that, under the influence of the gouty diathesis, there is a superabundance of the urate of soda in the blood and in the humor*, to speak in the medical language of ancient days ; urate of soda likewise constitutes those articular deposits which at all times have been markedly noticed in the gouty. But this excess of uric acid does not manifest itself by an augmentation of the renal secretion, but seems, on the contrary, to coincide with a faulty elimination. THE DISEASES OF OLD AGE. 45 LECTURE IV. PATHOLOGICAL ANATOMY OF GOUT. Summary — Local Changes in Gout — Condition of the Articulations — Diarthrodial Car- tilage — Deposits of Urate of Soda occupy by Preference those Tissues Deprived of Vessels — Condition of the Synovial Membranes and the Ligaments — Tophus (Chalk-Stone) ; its Composition — Inflammatory Phenomena — Dry Arthritis — Anky- losis — Place of Election of Gout : Articulations which it may Invade — Peri- Ar- ticular Tophaceous Concretion — Deep-seated Cutaneous Concretions — Tophus of the External Ear — Enumeration of the Principal Points where a Tophus may Form. Gentlemen : — In the last lecture we have seen that, at all periods of its evolution, gout coincides with an excess of uric acid in the blood. To-day we are going to show you that the local changes in this disease arise, for the most part, from the direct consequences of this general alter- ation, and that the deposits which are met with deep within organs or tis- sues are almost always formed of urate of soda. The knowledge of the changes to which we invite your attention is not confined to modern days. Long ago it was known that, in gouty patients, tophi and chalky deposits formed around the joints ; but these were looked upon as exceptional occurrences, and were thought to be peculiar to the gravest and most inveterate cases. It was reserved for Garrod to show that the slightest attack of gout leaves an indelible imprint upon the tissues it in- vades, and that the latter are forever stamped with its seal. Let us begin by studying what occurs in the diseased articulations : there we shall see gout manifesting itself by truly peculiar and constant anatomical characteristics. L — From the very first attack deposits of urate of soda fomi in the ar- ticular ' (diarthrodial) cartilage ; 2 they occupy the most superficial portions of the cartilage, and are lodged either in the space between the cells, or in their very interior — a fact which Cornil and myself have established. They are generally located about the centre of this free surface, as far as possible from the insertions of the synovial membrane, which stops, as you know, at the circumference of the articular cartilages. It is not difficult to comprehend the reason of this singular choice. The points accessible to the circulation are the least liable to the forma- tion of these deposits which occupy preferably those tissues which are de- prived of vessels ; now, synovial membranes and bone possess an eminently vascular structure, and thus gouty concretions form on the surface of the cartilage so as to be separated from the bone, and form at the centre of this- surface so as to be removed from the synovial membrane. 1 Garrod : On Gout, p. 211. London. 1*63. - Articular, also called diarthrodial cartilages, and "cartilages of incrustation " (cartilage d'encroutement). — L. H. H. 4(3 CLINICAL LECTURES ON At a more advanced period of the disease, when the chronic stage has succeeded the acute, the synovial membrane itself then suffers invasion, and the appendages of the fringe-like processes at the margin of this mem- brane, being less rich in vascular supply, are the first to be attacked ; later on the synovial membrane itself presents incrustations. It is then that de- posits form in the epithelial cells, according to Professor Eouget ; and the whitish sediment or mud — (boue blanchatre) — which is sometimes observed in gouty articulations is nothing but urate of soda proceeding from epithe- lial desquamation. "We know, indeed, that the ligaments themselves at times participate in this process of incrustation. But it is not even here that the pathological process ceases ; it may go farther and invade parts extraneous to the arti- culation; the tendons and the synovial sacs may become the seat of it, and when a concretion develops in the adjacent cellular tissue it receives the name of tophus, or chalk-stone. Sometimes, you know, it attains a consid- erable size. These extra-articular lesions, however, which correspond to a more advanced state of saturation, are always secondary to those changes in the diarthrodial cartilages, which may exist alone, but which can never be absent when deposits of urates have occurred in the circumference of the articulation. At least, we know of no case which forms an exception to this rule. And now let us see what is the composition of the material that con- stitutes these deposits. Examined with the naked eye, it appears amor- phous, and resembles plaster-of-Paris ; but, viewed microscopically, it seems to be entirely formed of needle-like crystals. It is true that you sometimes find masses of amorphous matter disseminated throughout the affected cartilage ; but Garrod claims that by means of the polariscope you can es- tablish the fact that these agglomerations are themselves | I of a crystalline structure. When acetic acid is employed, rhomboidal crystals of uric acid are pro- duced, and it is by means of this reagent that we can prove the jam of depositions in the interior of cartilage-cells. Bat we her means for determining the chemical composition of these incrustations : if the affected cartilage be treated first with cold water, then with alcohol, and next with hot water, it becomes perfectly transparent, and the reagents that have been used in this washing deposit, upon evaporation, crystals of pure urate of soda. These crystals, when incinerated, produce carbonate of soda; treated with fuming nitric acid, and then with ammonia, they give rise to purpurate of ammonia, or mwrexide, whose color is so character:- But we shall not further urge the chemical part of the question ; it will be sufficient to remark that the cartilage, when thus rid of its incrus- tations, presents a perfectly normal structure, with no change visible either under the microscope or to the unaided eye. At least, this is the general rule. As for the liquid — often muddy — contained in some instances within the articular cavity, it quite often has an acid reaction, presenting micro- scopically epithelial debris and needle-shaped crystals. II. — Let us now point out some other lesions, which, though they are not constant, none the less merit a detailed description. "When a gouty articulation is opened just after an attack, the synovial membrane is almost always found red, injected, and vascularized: but while these phenomena never go on to suppuration, an excess of fluid is, how- ever, often found within the articular- cavity. THE DISEASES OF OLD AGE. 47 In cases of inveterate gout all the lesions of a dry arthritis may be met with at the diseased point; and consumption of the cartilages ("asur"), secondary ulcerations and osseous swellings, have all been remarked by various observers. Indeed, I have myself seen some cases where they were present ; but they are exceptional occurrences, whose nature is as yet not well understood, but which deserves a very attentive study. Do you see in these peculiar cases a kind of transition between gout and rheumatism ? Can it be that they are the results of a kind of com- bination of these two diatheses ? Or is it only a question of a simple com- plication ? This is a question whose answer, it seems to us, ought to be postponed. Finally, ankylosis may be the result of the changes which have just been described : sometimes it amounts to only a simple rigidity, the result of incrustation of the ligaments ; but true osseous ankylosis is also met with, as has been remarked by Garrod and by Ranvier. Indeed, this may come from the very first attack, as Todd and Professor Trousseau have pointed out. 1 m. — Gout does not impartially choose its seat from all the joints, as was well known in the days of remotest antiquity, for the metatarso-pha- langeal articulation of the great toe enjoys the unpleasant prerogative of most frequently drawing down upon itself the manifestations of this dis- ease ; then come the fingers, followed, after a long interval, by the knees and the elbows. The hip- and shoulder-joints are usually spared. Sometimes, however, the great toe is not attacked by the gout while other articulations are being invaded ; and this is a fact of great practical importance, since it allows us to understand why general acute gout some- times presents such a strong resemblance to acute articular rheumatism, and to explain how it is that certain observers have been led to confound 2 the two. It is evident, for example, that an attack of acute gout, occurring simul- taneously in the knees and wrists, would be very difficult to distinguish, at the bedside, from a purely rheumatic affection. Among the rare and exceptional cases we may mention those where gout attacks the vertebral column, the temporo-maxillary articulation (Ure), the arytenoid cartilages (Garrod), and finally the ossicles of the ear (Harvey) : this results in a new species of deafness. IV. — From this necroscopic study we shall deduce a number of consid- erations, the importance of which, from a clinical standpoint, is incontes- table. First. — At once let us observe that the incrustation of cartilages is in- separable from articular gout, and seems to begin with the first attack. Second. — In a gouty patient the diseased joints alone present this lesion of their cartilages, and now and then it is found only in a single articula- tion. Third. — This incrustation of urate of soda goes on independently of the paroxysms or attacks, and in the interval between them it may not reveal itself upon the exterior of the joint by any appreciable deformity. 1 Todd : Practical Remarks on Gout, p. 45. London, 1843. Trousseau : Clinique Med. de l'Hotel-Dieu, vol. iii., p. 328. 5 In the original it reads : " amenes a les comprendre." I have taken the liberty to substitute confondre in correction of what I deem a printers error, the context cer- tainly pointing to confound instead of comprehend. — L. H. H. 48 CLINICAL LECTURES OX Fourth. — This lesion is peculiar to gout, and never occurs in articular rheumatism, whether acute or chronic. There yet remain the questions : "What relationship subsists between an attack of gout and the formation of a deposit ? Is the latter phenomenon the cause or the effect of the symptoms which accompany it ? This last is a difficult question to answer, and we shall reserve its discussion for another time. V. — We have seen that deposits of urate of soda form upon the exterior of diseased articulations. They are met with : 1st, in the tendons, and more particularly in the tendo Achillis ; 2d, upon the periosteum, but never in osseous tissue ; 3d, in the serous sacs (the olecranon and patella's) ; 4th, in the subcutaneous cellular tissue ; and 5th, even in the deep layers of the skin. The last two points especially deserve consideration. The subcutaneous depositions which form in the vicinity of joints con- stitute a very important part of the symptomatology of chronic gout, for they often manifest themselves during life. They are known by the name of tophi, tophaceous concretions^ OTchali>stones — terms which are very frequently misapplied. They are exclusively given to the peri -art icular collections of urate of' soda, and ought never to be employed to designate the osseous tumors of chronic articular rheumatism. In the earlier stages of their development these chalky masses have a soft and doughy consistence ; later on they harden, and acquire a certain degree of solidity. From a chemical point of view, they are conipo- urate of soda, mingled with the urate and phosphate of Hme. Microscopi- cally, they present very tine crystallized needles. Their favorite seat is in the hands and upon the surface of extension ; but they are equally found about the great toe and at other localities. They are ovoid tumors with an irregular surface, sometimes be: sometimes having a pedicle, and at times attaining a volume equal to that of a pigeon's eg;g ; they are in the immediate vicinity of the joints, without exactly resting upon them ; being movable laterally, they do not pn reproduce the form and the contour of tl. afl in juxtap. - with them. They exert a lateral pressure upon the joints which do* always deform them ; they present no symmetry in their mode of distribu- tion ; the skin covering them is shiny, sometimes being of a dull white color, and with transmitted light you may be able to see the subjacent de- posits. These various properties enable us to distinguish the tophus from those characteristic deformities of nodular rheumatism which we shall atndj later on in the course. But we must not overlook the fact that b very difficult cases occur, in which there is an angular deviation of the lin- gers analogous to that met with in chronic rheumatism. Here the consid- eration of the articular deformities alone will not suffice to establish a diag- nosis, if no external tophi exist. You must, in that emergency, rely upon those general or local phenomena which, taken as a whole, characterize the gouty diathesis ; and you may even meet with cases where it will be D sary to have recourse to a chemical examination of the blood before arriving at absolute certainty in your diagnosis. XI. — These concretions which form in the deep layers of the skin, also offer, from a practical point of view, a special inter. The deposits in the external ear* described by Ideler, Scudai:. THE DISEASES OF OLD AGE. 49 Professor Cruveilhier stand in the foremost rank ; and Garrod lias shown how great an advantage may be taken of them, in respect to the clinic. The seat of these little concretions is generally upon the edge of the helix, but they may occur in the anti-helix or on the internal surface of the auricle or pavilion of the ear. They pass through three stages of de- velopment : at first soft and pulpy, they next become hard, and form small, whitish masses ; finally they may fall off, leaving behind them a small cica- trix whose existence may be proven when the tophus itself has disappeared. Of 37 cases Garrod found external tophi in 17 ; upon the ear alone in 7 instances, and upon the ear, and near the joints, 8 times ; once only on the line of an articulation was a tophus found, without a coincident, similar de- posit in the ear. These decisive indications sometimes become manifest very early ; I have been able to predict in advance, simply by the presence of a tophus in the ear, the outburst of gout in a dyspeptic patient, in whom, neverthe- less, articular symptoms had never appeared up to the time when he con- sulted me. Garrod witnessed the formation of these concretions in one of his patients five years before the appearance of any symptoms in the joints. 1 In this way one readily understands what importance they have i'rom a diagnostic standpoint. When concretions upon the external ear are wanting, the following parts should be examined : 1st, the eyelids ; 2d, the ake of the nose ; 3d, the cheeks ; 4th, the palms of the hands ; 5th, the corpora cavernosa. Upon all these points cutaneous depositions have occurred identical with those which we have just described. It now remains for us to speak of the pathological anatomy of visceral gout, and to that we shall devote our next lecture. 1 These exceptional cases do not, however, invalidate the general rule. Articular symptoms almost always precede the formation of these external deposits. 50 CLINICAL LECTUKES ON LECTURE Y. PATHOLOGICAL ANATOMY OF VISCERAL GOUT. Summary. — Retrocedent Gout ; Functional Lttiont of Goat — Inmost Instances after an Autopsy has been made, these seem to arise from Material Changes — Organic Lesions most frequently met with in the Viscera of Gouty Subjects — Fatty Degeneration of the Heart — Atheroma of the Aorta— Bronchial Lesions — Gouty Nephritis : Its Two Distinct Varieties — Gouty Kidney of the English : Lesions Corresponding to this Designation — Deposits of Urate of Soda — Bright's Disease — Interstitial Nephritis. Changes Analogous to Gouty Changes in Animals — Do n Mammals — Occur in Certain Birds — Similar Lesions in Reptiles — Experiments of Zalesky — Results of Ligation of the Ureters in Different Animals. Gentlemen : — If gout were a more common affection in our hospital - would i)robably be better Acquainted with the pathological anatc my of the visceral lesions that may arise from this i aware, the opportunity of making an autopsy of B gouty sub;. rarely i re- sents itself in France. The English authors fare much better in thi- ter, and they have given us some very in! details concerning the subject. It may be stated, however, in a general way. that little is known of the whole question, at least wit: the anatomical h - Gouty nephritis alone stands as an exception to this rule ; and for this reason it behooves us to study it with particular care, after rapidly outlined the state of our knowledge touching the other tions of gout. I. — We shall first consider those sudden modifications, occurring in the course of gout, which have received the name of met.. sions. In such a case one would evidently suppose, upon a t that it is only a question of mere superficial lesions, esi>ecially when the symptoms are not followed by a fatal issue : it does not seem probable that the dis- eased organ could be the locus of deep-seated changes, and one would rather be disposed to class derangements of this kind under the head of functional lesions. But here the stamp of pathological anatomy is almost completely wanting, by very reason of the rapidity with which these B toms disappear in the majority ot" Cftf Still, we do not always find things happening in this v :h is sometimes the result, and one may be called upon to make th< In such cases organic lesions have often been dis. .ml. in ti gard, we \ vera! observations which are worthy of credit ( of these cases, which were accompanied by gastric Bym] I under the observation of Dietrich, Perry, and Budd. The pal cumbed with the classical symptoms of gout in the stomach ; and an matous swelling of the submucous cellular tissue of ;' covered, along with more or less marked changes within the mucous membrane itself. THE DISEASES OF OLD AGE. 51 In other cases, where the patients rapidly sank during the course of a gouty attack or fit, the ordinary lesions of a cerebral hemorrhage have been discovered, and sometimes even rupture of the heart has occurred. If it were allowable to judge in view of these examples, we would be in- duced to believe that, even in those cases where functional derangements manifest themselves upon the occasion of gout, they nevertheless corre- spond to organic changes less superficial than generally supposed. But there are other lesions which seem to be connected with this dis- ease, which have been met with in subjects who have suffered from either acute or chronic gout, when an intercurrent disease, or the progress of the gout itself, has induced a fatal termination. These we shall hastily review. A. — The muscular walls of the heart are often affected with fatty de- generation. S. Edwards, Lobstein, and some other observers, have found urate of soda in valvular concretions, although Garrod contests the accu- racy of this statement. B. — The aorta is often the seat of atheromatous change ; moreover, urate of soda has been discovered in its walls by Bramson, Bence-Jones and Landerer. C. — Bence-Jones has asserted the experience of urate of soda in the walls of the bronchial ramifications. D. — Up to the present time no special change has been ascertained to to be present in the brain, meninges, or in the encephalic arteries. E. — The kidney-changes in gout, ordinarily described under the head of gouty nephritis, are to be divided into two varieties. In the first place we find the disease described by Bayer under the name of goaty nephritis, which may be properly denominated gravel of the kidney. It presents the characteristics of chronic interstitial nephritis, but is pre-eminently marked by infarctions of fine gravel and uric acid, the latter sometimes in a crystalline condition, although larger-sized gravel may also be present. These deposits occur ; 1st, on the surface of the kidney and deep in the cortical substance ; 2d, in the mammillary elevations and papillae ; 3d, in the calices and infundibula ; upon the last-named part the concretions are generally large in size. These changes may also occur apart from articular gout, but they are undoubtedly of very common occurrence in this affection. In the second place we have what is properly called gouty nephritis ; this is the gouty kidney of English writers. Signalized by De Castelnau in 1843, it has been excellently described by Todd and Garrod. Anatom- ically it is characterized : First. — By urate of soda infarctions in the form of white streaks (trai- nees blanchdtres), which are found in the tubular substance (never in the cor- tical portion), and, in some cases, in the pyramids. Microscopically, they appear in the form of crystalline needles, whose seat, according to Garrod, is in the spaces between the uriniferous tubules ; although we believe we have proved that their starting-point is in the very canal of the uriniferous tubules which are obstructed by them. 1 Second. — It is characterized by concomitant changes within the kidney, which correspond to the ordinary lesions of Bright's disease. At first there exists a parenchymatous nephritis, 2 which may appear in 1 Charcot and Cornil : Memoires de la Societe de Biologie. 1864. 2 Loe. cit. 52 CLINICAL LECTUEES ON one of two different stages. In the first stage the kidney preserves its ordi- nary size, but the cortical substance becomes thicker and presents a yellow- ish tint. The Malpighian corpuscles are injected, the uriniferous tubules are filled with epithelial cells which are distended, opaque, and full of fatty or proteid (albuminoid) granulations. In the second stage you find atrophy of the cortical substance and that granular condition of the kidney belonging peculiarly to Blight's disease. But, besides this parenchymatous nephritis, you also meet with the in- terstitial nephritis corresponding to the gouty This is especially characterized by a thickening of the intertubular nective tissue, and a proliferation of nuclei (cells, , The volume of the kidney is diminished, and its bu] wrinkled, granular, The cortical substance is markedly atrophied. In this have never been seen in a waxy condition. According to Garrod. I in all cases of ur- ate gout where an autopsy has been made ; and t. early in the disease, having tack. In one case recorded by Iran tion occurred only one year ;iftcr ti was undoubtedly a viscera] form of the i Although the changes in the parenchyn excepting in the deposition of in la, from those winch < rial in ordi- nary Blight's d sptoms hi cmtj albuminu- ria are remarkable on account of intensity which they pn at 1 do 1. . dwell i. which belongs to symptom To this kind of c quently figure in the train i^i tl. is often aggravated, if not who that pat] lion of tlte kidney; and again, o d.tna ifl fcly a COM Uraemia is seen in the convulsive evidently arises from tl. hypertrophy-— both of those may he reckoned among quenceS of the renal lesion. H — This, gentlemen, finishes the sketch of the anatomical lesions which characterize the gouty diathesia Bui it profitable to look at certain beta con© experimental pathology, which Beam I With a powerful light those questions which we ha I those also which we shall next oonsidi Can gout occur in animals ? And. supposing that it it produce results comparable with those it causes in the humai In a recent work upon comparative path* the negative. He rightly ol been designated by this name ought I m d under the head rheumatism. At all events, it is incontestable that a disease analogous to gout in man, develops, and is characterized, like by deposits oi urate of soda in the various tissues of the body. We do not find our points of comparison among am. be led to suppose from the anal in captivity and placed under special conditions. You will be aished at finding, in tli< - :reat class' - mals, disease presenting some point ( THE DISEASES OF OLD AGE. 53 member that tlie work of disassimilation in them does not produce urea, but rather urate of ammonia, as Davy and other chemists have shown. Gentlemen, authors of the various treatises upon ornithology will tell you that, in certain birds, there may exist lesions closely analogous to those of gout. Aldrovandi teaches us that, in the falconidce, tumors made up of masses of gypseous matter are liable to form around the toes. This is an incurable condition. Analogous phenomena occur in parrots. Bertin of Utrecht found, in the Fsittacus grandis, urate-tumors in the vicinity of the joints, and similar infarctions in the articulations and in the kidneys. Lesions of a similar character have been pointed out in the case of rep- tiles. Pagenstecher observed the kidneys and joints of the Alligator sclerops affected in this way. In ojjhidians these changes may exist in the kidney, and in the tortoise Bertin has likewise found both articular and renal lesions. It is curious thus to meet, in animals but remotely related to man, these lesions, which, in all respects, are so strikingly analogous to those of gout. But a still more remarkable fact is that these lesions may be artificially in- duced by means of physiological experimentation. This is the result of an interesting work published at Tubingen, by Zalesky. This experimentalist ligated the ureters of chickens, geese and adders (Coluber natrix). The first morbid phenomena appeared in from twelve to fifteen hours after the operation. Life was prolonged over two or three days, and, after death, urate of soda was found in the following viscera : First. — The kidneys exhibited it within their tubules, but not in the cortical substance. The ureters likewise contained it. Second. — The lymphatics, serous membranes, the cellular tissue, and the capsules of all the organs, were impregnated with it. Third. — The stomach-folhcles contained a remarkable quantity of it. Fourth. — It was found in the valves of the heart. Fifth. — The joints exhibited, both intra and extra, a considerable accu- mulation of this product. There was no deposit of urate of soda in the muscles, but the mus- cle-juice contained a great deal of uric acid. The brain and its membranes seemed to be wholly exempt. Concerning the fluids of the economy, the blood contained marked quantities of uric acid, and after death clots were found composed of alkaline urates. Finally, the gall-bladder contained an enormous amount of urate of soda, a new coincidence with human pathology ; for in man, according to Frerichs, calculi composed of urate of soda are sometimes found in the gall- bladder. In order to accept unreservedly these data, the experiments must be renewed and varied; the effects produced by the ligation of a single ureter, for example, must be studied, in order to see whether, after a certain lapse of time, the same results will not be produced. It is none the less true, however, that Zalesky's experiments possess great interest, and deserve to be seriously considered. Gentlemen, though this excursion into the domain of comparative pathology may seem a little unusual to you in a clinic, you must not be as- tonished at the importance which we attach to these facts. We shall meet them again at the time when we shall endeavor to argue a physiological theory of gout. 54 CLINICAL LECTURES OX LECTURE VI. SEMEIOLOGT OF GOUT. -URIC ACID DIA -ACUTE 6 NIC GOUT. Summary —The Two Principal Forma of Goat ; Aent* and < * ways Essentially a Chronic Affection ; but the Appearance from the Permanent Comi which Collectively Characterize it in Solid Matter— M: Gravel-Acute G- Articular Pains-General E aaracterwtic. « I '*— Secondary Phenomena-Devi;, Gout- Asthenic or Atonic Gout- I. Transformation of Acute into Chronic current Diseases-Chronic Gont following A< ■ «* Onset— Development of a Tophus. Gentlemen :— Heretofore the anaioi sively occupied our attention. \\ l the fluids and solids of the of this disease, and it now remains for o toms arising from the l At the beginning of these Iftoturcf we eetnbli acute or chronic, gout appears which merits a special description. It that in every case gout is an t a» otialh first attack is but the primitive which after this initial paroxysm ma} a certain number of years, but whic new symptoms. If there d< single attack, they are phenomena of ■ fWfj n kind, and cai invalidate the general rule. Still, the aspect of an acute attack is B sented by the disease when in its p to respect these expiree I by us.. their inexactitude, undoubtedly coir. We are about to study in - in this way conforming to the universally a entering upon the subject, it is p r oper I condition which sometimes mai lar symptoms, and which, in those who are alre:i< often tills in the intervals between its recognized as the uric acid diathesis. Let condition for a few moments, a condition which is known ohii eana of English writers. ' 1 Todd : Practical Remarks on Gout -oorgv) : I >f tiie urinary secretion in such a case? In a general way the urine is scantier, but richer in solid matter; it is diminished in quantity, but rery acid and high-colored; it is loaded with sediment, which usually forms utter voicing of the urine, but which may be already formed within the bladder. In such eases crystals of arte acid are very frequently met with in the urine; this constitutes Bayer's microscopic graveL When (he uric acid diathesis appears before the articular phenomena of gout, one may dem cue instances, the existence of an e of uric acid in the blood from that moment And. besides, the whole series of symptoms we have just been describing occur especially during the in- terval between the attacks, when rheumatoid pains will manifest themselves in groups of muscles, and in those articulations having a predilection for inflammation. These pains appear abruptly in the form of twinges, and during the absence of articular inflammation, they constitute one of the most characteristic evidences of gout, sometimes, indeed, preceding the outburst of the disease. Gentlemen, there are, undoubtedly, cases in which this condition of affairs may remain unaltered, and in which the predisposition giving rise to the uric acid diathesis never receives the last factor in this morbid pro- cess, just as gout develops, in certain subjects, at the initial attack or paroxysm ; but the general rule is, that upon this pathological foundation is developed gout properly so-called, and this development of gout we shall now commence to study. Acute Gout. Let us suppose that a first attack of gout is on the point of breaking forth in one who, up to this time, has never felt a touch of this disease. In the majority of cases special prodromata announce the coming of the attack ; 56 CLINICAL LECTUEES ON sometimes there will be an extreme exacerbation of all the symptoms re- sulting from the uric acid diathesis, which I have just been describing to you ; and, at other times, on the contrary, there will be an abnormal feeling of well-being, a peculiar excitation. Finally, in a few cases you may ob- serve the production of phenomena wholly unknown to the patient's experi- ence, as, for example, an angina, a sciatica, or muscular pains. Still, you must recollect that in a certain number of cases there may be a complete absence of prodromata, the attack then commencing abruptly in an abso- lutely unforeseen manner. The occurrence of articular pains is rapid and violent, almost always taking place during the night. The patient suddenly feels a characteristic pain, likened by some to a bite, and by others to a blow from a cudgel ; many imagine that they have suffered a sprain, and on the first view the diagnosis is somewhat difficult. The most frequent seat of these sensations is the metatarsophalangeal articulation of the great toe. Soon n and swelling appear at the point attacked ; there is enlargement of the veins of the affected member, which assumes a purple color. rding to Gairdner, is now and then covered with ecchymoeea. Fluctuation, some- times apparent, sometimes real, is developed at the same time ; and when real is caused by the presence of an excess of fluid within the articular synovial membrane. The general symptoms accompanying these local manifestations are fever, irregular chills, nervousness, and great irritability; and, finally, a marked diminution in the quantity of the urine, which upon coolin _ posits a very copious sediment. Toward morning the pain and most of the other symptoms rem reappear that evening or during the night. This condition oontinui five or six days should medicine have been adminisl bt or fifteen should no medicines have been employed (G then, a kind of chain of short attacks linked one to another, an intervals of remission. In the first days of the attack marked oedema appears in the inflamed parts, soon extending over the whole member, and pitting The decline is characterized by superficial desquamation. Ultimately i thing is restored to a normal condition ond the patient ei - • . only to be broken by the next crisis. Thus you see that, to sum up, the salient features of acute gout are the following : Mrst. — The abrupt invasion and the special character of the pail Frenchman, quoted by Watson, 1 comparing the Benaation which he h often experienced with the effects of great pressure, said that rheum was the first turn of the vise ; but, give it another turn, and you had _ Second. — QSderua of the member at the commencement of th and desquamation of it toward the decline. Third. — Absence of suppuration. Fourth. — The special seat of the symptoms, their favorite location being the great toe. Fifth. — A febrile reaction whose degree of intensity is j the number of joints affected, contrary to what is obeerv< articular rheumatism. 1 Principles of Physic, etc. Vol. h\, p. 7 -I have heard it also put thus: "Screw up the viso ill have rheumatism ; give it another turn, and that is gout."-- L. II. H. THE DISEASES OF OLD AGE. 57 And finally, when taking the secondary phenomena into account, the most striking occurrence is the relief felt by the patient after the attack ; and this feeling of comparative well-being probably corresponds to the destruction of a certain quantity of uric acid. Along with this change in the general condition, we ought to describe the alterations occurring subsequently in the local state of affairs. Follow- ing the first attack there is, in the vast majority of cases, no restraint what- ever to the articular movements ; but sometimes you notice prolonged rigidity of the articulation, or an indefinite persistence of the oedematous swelling. These, according to Garrod, are the results of injudicious treat- ment — such, for example, as the application of leeches to the affected part. In some cases — happily very exceptional ones — ankylosis occurs at the commencement (Todd, Trousseau, Garrod); and, in other cases, there are premature formations of tophi or chalk-stones. This, gentlemen, is the commonest type of an attack of regular acute gout. I should undoubtedly have been able to draw a more animated pic- ture of it, if I had not restricted myself to follow an analytical order. But you can readily console yourselves by reading the immortal description left by Sydenham, or the eloquent pages Professor Trousseau has devoted to this subject. And now, let us see what are the principal deviations which may be pre- sented by the regular type I have just been describing. Let us first consider the deviations which gout may undergo with regard to the situation of the articular symptoms. Usually, or rather, let us say in the vast majority of cases, the great toe is the part affected — sometimes of one side only, and again of both sides consecutively. Scudamore found that, in 512 cases of gout, the great toe was attacked 373 times at the first fit, either alone or in company with other joints ; and of these 373 cases there were 341 in which the symptoms were mono-articular. It is very clear that, from a diagnostic standpoint, the greatest advan- tage may be derived from this strange predilection. For in this regard an unmistakable difference subsists between gout and articular rheumatism. Still, there are cases where the great toe is only affected secondarily, the disease primarily appearing at some other point, as, for example, in the knee. Traumatic causes seem to play a very important part here, a blow or a fall predisposing (as in rheumatism) the injured articulation towards becoming the seat of gout ; but we shall return to the subject of etiology farther on. Exceptional cases do exist where the great toe remains perfectly exempt, both at the first and at the subsequent attacks. Garrod describes cases of this sort, and I have myself noticed a few of a similar character. Gout, then, can be located in the knee or any other joint from the first attack. ■ Finally, there is a form of the disease that deserves special attention, since it presents the greatest analogy with acute articular rheumatism, at least with respect to the symptomatology : I refer to acute primitive general gout, which, from its very first attack, invades several joints at the same time ; a great number of the articulations, large and small, may be affected simul- taneously. Here the attacks are of longer duration, persisting during two or three weeks, and may even be prolonged over several months. This is the " gout with successive paroxysms " of Professor Trousseau. How many times have not these symptoms been attributed to acute articular rheuma- tism ? But acute gout presents variations not alone with regard to the seat of its manifestations ; but the intensity of the principal symptoms, the pain, 58 CLINICAL LECTURES OX the general reaction, may suffer a strange diminution. This is quite fre- quently the case with women and debilitated patients, and is the mild, atonic, or asthenic form of acute gout, whose progress is generally unfavor- able, and which readily passes into the chronic state. But, as we have already once observed, gout is essentially a chronic affection, even in its acute form. And hence, it is indispensably necessary to study the attacks taken in connection with one another, to follow them step by step in their repeated returns to the onset, and to describe the charac- teristics presented by the successive attacks. Return of tine attack. — At the commencement gout seems to accord quite long periods of rest to its subjects : only one attack occurs in two or three years. Later on the symptoms recur annually, and next tie in the year — in the spring and in the fall — a sign that th< i been a change in the usual pathological occurrence- generally makes its appearance at the close of winter (Trousseau). At last the intervening periods grow smaller and smaller, and the at- return every third or fourth month. Already the chroi entered upon. You must recollect, in addition, that accidental conditio 1 vene or derange this regular progression ; a traumatic lesion, phl< an erysipelas sometimes occurs to accelerate the advance of ti. or to induce sudden and unexpected returns of it. Characteristics of the new attack*. — For quite a long period tin striking modification of the symptoms which collectively mark tl Restricted to one or two joints, the articular inflammation oontio cupy the same locality, while the general symptoms still pn degree of intensity, the intervals between the attacks 1 morbid manifestations. However, as the disease pro- and it displays a tendency to assume the chronic form. large joints are seen to under . md thai always the following order : the toes, the ins! the hands, the wrists, the elbows, and finally in r and the hip. Then the patient, struck by the unquesti . t dilv imagines that his disease has changed its nature and lu into rheumatism. At the same time the attacks, whose duration is now much pos- sess less intensity, taking on the subacute form, and much more slightly marked febrile reaction. T free from morbid phenomena, and the symptoms of abarticular more and more pronounced : the patient is now troubled m< n the past with dyspepsia, palpitation, and various nervous d< rang* word, it might be said that the disease, at first con becoming diffuse ; it gains in extent what it loses in d< pth. Bui froi very moment it is chronic gout. Let us, then, study the eh . this latter disease. Chbgbxo Goit. This form of gout has for its essential character eneral depression of the vital forces of the economy, expressions atonic or asthenic gout, applied to it by bosh THE DISEASES OF OLD AGE. 59 in reality a pronounced feebleness and a tendency to a cachectic condition always do appear — in different degrees of course — when the disease has reached this point. And moreover, intercurrent affections display, in these cases, a most exceptional gravity — influenza, pneumonia and typhus have here an unusual progress, the last-named disease nearly always proving fatal (Schmidtmann, Murchison) ; and in this respect there might be estab- lished an analogy between gout and diabetes — a view which, later on, will be justified by other points of comparison. We know that here there exists a permanent alteration in the blood and in the urine, which in certain degree explains to us why the intervals be- tween the attacks are full of more or less serious abarticular symptoms, such as palpitations, dyspepsia, and nervous derangements. And it is like- wise under the influence of this alteration that the tendency to certain organic visceral affections seems to be generated, the implicated organs being the kidneys, liver, heart, and the vascular system in general. But chronic gout, though ordinarily succeeding acute gout, may also assume the first-named form from the onset, and in that case it presents slightly different characteristics. First. — Following acute gout, chronic gout is established very nearly permanently in the articulations, though the local symptoms become less acute and the pains less intense. And lastly, as I have already observed, the upper extremity begins to suffer the invasion of the disease ; now it is at this period that you notice articular deformities; it is at this period especially that you observe the production of those tophaceous concretions which are soon to demand our attention in a very special manner. At the same time, the change which has taken place in the constitu- tional condition is exhibited during the attack b} r a reaction which has lost much of its intensity, and during the intervals by more pronounced symp- toms arising in the viscera. Second. — When, on the other hand, gout is chronic from the very com- mencement, the tophi are seen to form quite early, especially upon the hands. This is the stationary, primitive form of gout, in which local symp- toms depend almost exclusively upon the presence of deposits of greater or less size. Here we find grave visceral affections manifesting themselves at an early day in a certain number of patients : Todd has observed albuminuria ap- pearing two years after the beginning of the disease ; and two years later the patient was seized with epileptiform symptoms and died in coma. In another patient (reported by Traube), albuminuria existed within one year after the first symptoms of gout, and the body was already covered with tophi. We shall now consider the clinical characteristics of those concretions which we already know from an anatomical standpoint. And in fact, the tophi, when once formed, possess a certain kind of independent existence, that consequently entitles them to a separate study. Their diagnostic importance cannot be over-estimated, since they give rise to special deformities belonging exclusively to gout ; and, besides this, they are much more frequent than used to be imagined : Scudamore says you meet them ten times out of a hundred, and even that is frequent ; but to-day, taking into account the concretions upon the external ear, their existence, according to Garrod, may be affirmed in one-half of all cases. Their development, which was so excellently described by Moore in 1811, has three stages. Following an attack, in an interval of remission, 60 CLINICAL LECTURES 03" and sometimes without any pain, 1 a fluctuating fluid lifts the skin, as has been observed by Ccelius Aurelianus. In the second stage, these deposits solidify and assume the form of hard, indolent, more or less rounded m increasing with every attack, and even during the interval between them. And finally, in the third stage, the skin ulcerates, and there is an escape of chalky material, frequently in considerable quantity, from the aperture thus formed. When this elimination occurs without phlegmasic action, the cretaceous concretions are left bare ; in England old men with the gout are frequently seen to score their points at cards with the tophi covering their I which make a white mark upon the gaming-table like that of chalk. At other times a more or less intense inflammation is lighted up, and we have swelling, redness, then a purplish tint of the skin, and even threat gangrene; finally, an opening is made and pus and t the latter composed almost wholly of urate of soda, make their escape. In some cases this phlegmasia results in the formation of ulcere which are very difficult to heal. The urate of soda infiltrating the mesh-wi the cellular tissue renders it difficult to clean trices also have a tendency to reopen. Sometimes the articulations themselves may be encroi but it is worthy of remark that this occurrence portends no serious patient. The flow of this material often leads to local or general relief Garrodhas even stated that when attempts hare been made to n action by the application of astringents, urticular pains somen peared either at the point where the ulceration occurred, or distant spot. When it has readied its last phase, goal d< whose principal elements are marked anaemia, I especially in the lower limbs, and intense depression of the n< the patients are incapable of undergoing the least fatigue, and th< noise becomes intolerable. And here, gentlemen, we finish the clinical history of regular This form of gout is pre-eminently eharact. vmced, by a marked and frequently exclusive predilection for tl. tions. And this is the type which you will meet with oft practice, and which will be the easiest for yon I ize. We cannot say as much for the anomalous, tin r. the mi forms of gout ; for they sometimes assume the affections, those farthest removed from the gouty diath cian who has failed to become specially vera d in the di tins kind, is very liable to commit errors which may involve the deplorable consequences. Here, then, is a subject del attention, and all the more so since its study will enabl< one ol the most essential pointsof difference' be tw, t u ti, oi ancient days and that of conteinporarv science. We s subject m our next lecture. 1 I have recorded a case of gout, where the patient could aerer suffer ipt S!! f° ne Y r, any point whatever, without the imnu . at that spot.— JNote by the Editor. THE DISEASES OF OLD AGE. 61 LECTURE VII. SYMPTOMATOLOGY OF VISCERAL GOUT. Summary. — Predilection of the Ancients for the Study of Pathological Metamor- phosis — Importance of Masked Gout in this Respect — Scepticism of the Moderns — Definition of Visceral Gout — Functional Derangements : Organic Lesious — Masked, Misplaced, Retrocedent Gout — Can Visceral Gout exist Independently of all Articular Disease ? Diseases of the Digestive Canal — Spasm of the Oesophagus — Dyspepsia, Cardial- gia, Gouty Gastritis — Hepatic Evidences of Gout — The Circulatory Apparatus : Lesions of the Heart and Blood-vessels — Sudden Death — Cerebral Manifestations of Gout—Its Influences up ainples. An individual who, for a I denly suffers an attack of gout, and i- is so to all appearances ; but, omv the articttlai stomach is again troubled as of old. Tl. case of visceral gout, where the stomach f the articulations in the series of morbid mai after a fashion, to suffer in their stead. In lik< patient subject to epileptiform convulsions may b. cure of the nervous symptoms d several observations of this nature. In cases of this kind, the visceral affection - a a purely dynamie derangement; or, at best, only a superficial ch exists. And, besides, you readily understand how t: manifestations is subordinate to the locality they occupy. Very rarely, however, do you notice here tl italline d< urate of soda, which, in the cartilages and in fibrous as it were, the history of previous attacks. And I elements may be impregnated with urate of described— and still not present crystalline d< | essentially mobile in their nature: they appear and d they may coexist with, precede, or follow articular s majority of cases, they are seen to alternate with thex cases where the visceral trouble precedes articular gout, and, f shorter time, constitutes the only evidence of t: masked (larval, fame) gout is applied to it. \\ tollows symptoms occurring in the joints, it is , THE DISEASES OF OLD AGE. 63 vided, always, the metastasis has been brought about by the evident inter- vention of some external cause — as, for example, cold. Finally, we say that gout has retroceded of itself when the symptoms change their locality spontaneously. And here we have to solve one of the most difficult problems in the study we have undertaken. Can symptoms of visceral gout be present in a patient whose joints never have been and never will be diseased? In other words : can larval, or masked gout exist independent of articular gout ? It seems probable, at least ; and yet how many difficulties crowd around its demonstration ! Let us observe, however, that these phenomena may be present in one born of gouty parents, and who from the very outset is thus evidently pre- disposed to gout. Here is the first presumption in favor of the hypothesis we have undertaken to defend. In the second place, visceral gout appears in one of the forms which it ordinarily assumes, when it coexists with arti- cular gout. In the third place, there are eases in which implication of the joints shows itself as a rudimentary condition, evinced by painful twinges. And lastly, the uric acid diathesis, characterized by the group of phenomena which we have previously described, may give such an imprint of au- thenticity to these visceral manifestations of gout, that it can scarcely be called in question, when once the presence of uric acid i/i the blood has been established. There now remains the second group, that of organic lesions, which in the long run almost always succeed affections of the first kind, and have the same situation. Still, we are far from admitting that an absolute dis- tinction exists between these two orders of occurrences, while it is very reasonable to believe that the functional derangements are but the initial stage of those textural changes which give rise to permanent disease. It is imperative, gentlemen, that we should reduce the very compli- cated nomenclature of gouty affections to the simplest terms ; and to im- press these ideas yet more clearly upon your minds, we shall present a resume in the following table : [FUNCTIONAL i ff'dln-ral (preceding). Visceral Gout \ I Rtroctdent (following). (^ Anatomical, icitk permanent lesions. L — "We shall now study in succession the two forms of visceral gout which we have distinguished, in each organ and in each system that can become its seat. We shall begin with the digestive tract, for it is here that affections of this character are especially developed ; and it can be asserted with reason that "gout is to the stomach what rheumatism is to the heart." ' A. — We shall only say a word concerning quite a rare disease of the oesophagus, described by Garrod : this is a spasmodic constriction of the tube, obstructing the passage of the alimentary bolus. An attack of gout is followed by disappearance of this condition. B. — Next in order follows the discussion of gastric gout, a subject we have already slightly touched upon when speaking of the chronic dys- pepsia of gouty patients, as well of the nervous symptoms which accom- panied it. Masked (larval) gout of the stomach precedes the attacks or fits, and 1 Ball : These pour le Concours de l'Agregation, p. 158. 64 CLINICAL LECTUKES OX may even develop before any articular disease : in a very large number of subjects the gastric derangements undergo marked improve] a soon as the joints become implicated. In one patient — a case which I personally observed — the digestive trou- bles were present before the first attack of gout ; the diagn from the existence of a tophaceous concretion on t: d the subsequent progress of the symptoms completely substantiated ment. In another case there had been only a mingle attack of articular g Later on intense dyspepsia occurred, and, after having invoked the the regular practitioner to no purpose, the pal : union a homceopathist. An unexpected success crowned t; ment, and he was already congratulating himself for having to the "new medicine," when suddenly h< 1 with goat in the foot, thus affording an explanation of the miraculous core. B visceral manifestation of the diatl. Gout retroceded to tho stomach | from masked gout in the gravity it mi the opportunity of observing those omin< terminate in death. Gout, it is claimed, may retroced< metastasis of Guilbert. But much d induced by the intervention of a dirt the disease is broken by some violent emotion, by an atl or by ill-timed treatment : the patient, urg< d by hie unendui is imprudent enough to plunge the aff Parry), or to administer to himself some b colchicum (Trousseau, Potton de ] and swelling of the joints subside, he already felicil treatment he has resorted to. when the formidable ut in the stomach are suddenly s< rth. It is expedient to distinguish, at this point, with ' two symptomatic varieties. In ti in a cardialgic or spasmodic form : there is int. sure, together with a feeling of cramps in I same time marked distention of the stomach tacks of vomiting which are frequently uncontrollable, end grave general condition. Then algidity and cold s\\ pulse becomes small, frequent and in exhibited. In cases like these, according to Cullen, stimulation ! is to be employed, and alcohol in lar ^ In the second case the difl - an inilamin . There is intense epigastric pain, especially on pi vomiting occur, the matters being almost black, or a a more or less intense febrile movement, and folio- comes a condition of general prostration. Stimu ployed here, bloodletting being the treatment commended in these cases. \A here the general health is very poor, all I denly disappears, either under the influence of the | tion, or spontaneously with the gouty inflammation returnii toe. There is a general belief in the intliu - cations to the joint first affected, to recall to that spot a to have been displaced : but there are scarcely any vi to be iound in books corroborating the usefulm - THE DISEASES OF OLD AGE. 65 But science has recorded eight or ten instances where these symptoms have ended in death. At the post-mortem examinations which have from time to time been made, a thickening of the submucous cellular-tissue was discovered ; the mucous membrane of the stomach was cedematous and covered with hem- orrhagic erosions, and the cavity of the organ in some cases contained a black fluid. These lesions, collectively considered, seem to indicate that a change had already taken place at some distant period, notwithstanding the sudden occurrence of the disease. But, fortunately, these terrible cases are quite rare. Scudamore men- tions only two or three of them, and Garrod and Brinton never met with one. Quite recently Budd and Dittrich published two such cases. But, in a much milder form, gout in the stomach is quite a common disease ; it is chiefly met with in cases of asthenia and gouty cachexia, and in individuals who have abused specifics and the application of leeches and cold. It may be asked, however, if the existence of this disease has not been too readily admitted in a certain number of patients. It is unquestion- ably very easy for errors in diagnosis to be made here ; for hepatic or renal colic, the digestive derangements accompanying albuminuria, and perhaps even poisoning from certain remedies (from colchicum in partic- ular) — all these have more than once simulated gout in the stomach. A simple attack of indigestion, abruptly occurring in a gouty patient may possibly be mistaken for an attack of retrocedent gout, on account of the gravity often assumed by the symptoms, because of the special predisposi- tion induced by the uric acid diathesis. Thus, Watson remarks that we should say "pork in the stomach, instead of gout in the stomach." This scepticism has even gone so far as to almost absolutely deny the existence of gout in the stomach, and Brinton, after a long discussion of this ques- tion, finally concludes that a little gastric irritability may possibly exist in gouty subjects, but that anything beyond this must be regarded simply as a coincidence. We profess the opposite opinion in this respect, and after assigning a large share to errors in diagnosis, we believe that the various diseases which may be summoned to do duty in this regard are yet far from ac- counting for all the jmenomena. We have previously seen that physiolo- gical experimentation succeeded in producing in animals occurrences that were analogous to those of the gouty diathesis ; and in such cases we know that the gastric juices and the stomach-follicles become charged with urate of soda. While not pretending to call upon identical conditions to account for the phenomena of gout in the stomach, we think that superficial lesions can very readily be developed in the digestive apparatus under the influ- ence of retrocession ; and this view is perfectly confirmed by the results of autopsies made upon gouty patients who for a long period of time have suffered from their digestive organs. In such cases as these Todd has often discovered an enormous dilatation of the stomach, and Brinton has himself verified these results by personal observations ; this is the paralyzed and enfeebled condition of the stomach which Scudamore long since de- scribed as existing in chronic cases of this disease. And besides, it is probable that, after a time, permanent lesions are developed in subjects liable to these apparently functional manifestations ; and the fatal cases to which we have just alluded seem to afford the proof of it. C. — Corresponding to the two forms of gout in the stomach, above de- 5 06 CLINICAL LECTURES OX scribed, are two forms of intestinal dyspepsia : the first is characterized by attacks of spasmodic colic, and the second is a true enteritis. These phe- nomena may exist separately, or be joined to the various derangements of which the stomach may become the seat. n.— " The liver is rarely liealthy in gout " says Scudamore, and daily observation tends to demonstrate the truth of this opinion. There are, undoubtedly, diseases of the liver associated with gouty pepsia, and also transient enlargements of this organ which precede the attack, such as were observed by Scudamore, Galtier Boissiere, and Martin- Magron. But we are not yet absolutely certain whether there are permanent dis- eases of the liver which are the result of the gouty diathesis. Scudamore thinks that, in the end, the spleno-hepatic system feels the innuer gout, and becomes the seat of permanent disease. Besides, from the labors of modern physiologists, we know that the liver and spleen are probably the organs in which uric acid is formed. Still the anatomical character of this visceral affection (if it < mains as yet unknown to us ; and the lesions in the liver met with in [ subjects are almost always the results of alcoholisn. Biliary gravel, however, is sometimes coii. ith the uric diathesis and gout (Prout, Budd, Wunderlkh, WiUemin), tad then you may meet with uric acid calculi in the gall-bladder, accord; Stockhardt, Faber, and Frerichs. Still, the patients in whom ti tions were discovered might have been gouty. m. — The influence of gout upon diseases of the heart cannot 1 verted. But we are not concerned here, M in rheumatism, with sod ditis, pericarditis, or valvular IssJ when occurr. the gouty, seem to be caused especially by 1 i slooholi - The dominant condition here is a fatty tissue of the heart. Stokes, Quain, Gfsizdner, sod Qarrod all unite in affirm- ing the existence of this state of affairs. In the beginning this affection is present only in a sligl.- merely manifests itself by functional derangen and feebleness and irregularity of the pul retrocession is quite infrequent (Scudamoi rrodi. tl. a few cases of it, and death has even resulted from cardiac implication. In these cases, however, the lesions we are about to study had alread\ developed. In the second stage, we find fatty degeneration of the I v nrp- tomsof this disease are always the same, whatever 1 Garrod). They simulate functional derangement, end, being only slightly marked, the diagi rived at of exclusion. The cardiac impulse is feeble, almost absent ; the fl dull, and sometimes there is a niurniur resulting from fattv d tenser muscles of the valves. The precordial dulness '.v in- creased; the pulse is soft, compressible, intermit' ceedingly slow, especially during an attack or par pulsations); and finally, some have described I existing m those individuals whose cardiac muscular t:- this alteration. The rational symptoms are also quits capable of d THE DISEASES OF OLD AGE. 67 The attacks develop by paroxysms ; there are violent palpitation, dyspnoea, and a tendency to syncope ; and cerebral symptoms are seen to occur, assuming the guise of an apoplexy, although no intracranial hemorrhage has taken place (Law, Stokes). Sharp pains develop about the precordial region and shoot down the arm, thus simulating angina pectoris, which is itself frequently regarded as a disease of gouty origin. Finally, sudden death is a very frequent occurrence in these cases : thus, in 83 cases of fatty degeneration collected by Quain, death took place unexpectedly in 54, viz. : 28 times from rupture of the heart and 26 from syncope. In many of these observations the subjects were gouty patients. It is evident, then, that a goodly number of cases where death was attributed to gout in, or retroceded to the heart, were but cases of fatty de- generation of the organ. Quain and Gairdner witnessed death produced without rupture under these circumstances, while death from rupture was observed by Cheyne and Latham. The fatal termination has often occurred during an attack of gout, this latter condition seeming to act here as an incentive to the cardiac crisis. Lastly, let us note that an atheromatous condition of the arteries, very frequently coexisting with these cardiac lesions, may give rise to cerebral hemorrhages, in which case true, and not false apoplexy, is observed. IV. — Our ideas concerning the connection between multiple arthropa- thies and diseases of the nervous system have undergone a definite change — most occurrences of this kind used to be attributed to gout ; but to-day, rheumatism, through the researches of modern investigators, has been accorded the first place. Nevertheless, gout still retains its share in it, though it is interesting to notice that the two diseases have, in this respect, a parallel progression, and that all forms of cerebral rheumatism are found again in gout. Thus, the rheumatismal headaches described by Van Swieten, and more recently studied by Gubler, have their counterpart in the gouty cephalalgia which have so long been known, and which, in later times, have been so care- fully described by L} r nch, ' Garrod, and Trousseau. Acute delirium, or the meningitic form of cerebral rheumatism, occurs also in gouty patients, ac- cording to Scudamore. Rheumatismal apoplexy, or the apoplectic variety of cerebral rheumatism, appears in the form of stupor in gout, according to Lynch and Professor Trousseau. The convulsions manifesting themselves during the course of encephalic rheumatism are likewise present in gout ; though in rheumatism they especially assume the form of chorea, while in gout they are rather epilepti- form in character, as Van Swieten, Todd, and Garrod have observed. And, finally, we know the existence of a rheumatismal lunacy, which has been studied by Burrows, Griesinger, and Mesnet ; and the same is true for gout, according to Garrod. Lunacy, however, in the latter disease is rare, at least in France — Baillarger, whose experience is authoritative in these matters, having informed us that he has never met with a single instance of it. Just here let me remark, while pointing out a difference : that aphasia which is never present in rheumatism, (if we except cardiac diseases and secondary embolism), is met with, on the other hand, in gout. It must be 1 We recommend to our readers the memoir of Lynch as deserving of attention : Some Remarks on the Metastasis of Diseased Action to the Brain in Grout, etc. Dub- lin Quarterly Journal, p. 276. 1856. 68 CLIXICAL LECTURES ON confessed, too that encephalic derangements are, in general, less grave in gout than in rheumatism, that their alternation with articular phenomena is more marked, that retrocession is more palpable, and finally, that although there often exists a masked (larval) cerebral gout, this is very rarely the case in rheumatism. Cerebral symptoms of gout must not be confounded with delirium tremens occurring at the moment of the attack (Mareet), with the delirium which appears in acute intercurrent affections, or finally, with the symp- toms which dyspepsia, cardiac lesions, and anemia develop on the part of the nervous system with much greater frequency in gout than in rheuma- tism. In this regard, prolonged observation, and an attentive study of the patient during a long period of time are the only means by which all error can be avoided. V. — The influence of gout upon diseases of the spinal cord is still a mooted question. Todd and Garrod speak of the appearance of - symptoms, a sort of paralysis alternating with the attacks ; but not confound a lesion of the spinal cord with that in which follows intense paroxysms of articular gout, and which l iiilate actual paraplegia. True, Graves has reported a cat . upon an air a hardened and shrivelled condition of the curd v. .: this example does not appear to us to be quit' | must not be forgotten that if there do exist medullary diseases assoc: gout and rheumatism, which is as v< t anpfOfi are, undoubtedly, strongly marked articular d iiiently to lesions of the spinal cord, even if these be of traumatic origin.' VI. — The respiratory apparatus may lik. mie the seat of certain gouty manifestations, and these we shall rapidly pass in rev First. — Gouty asthma. — Among thoracic affections damnin g of this ap- pellation, there is one which corresponds to t nervous; the lungs are perfectly free during thi I between the attacks, and there is an evident alternation between the I tnd articu- lar symptoms. Dr. Vigla has reported a very interesting example of this kind to the " Medical Society of the Hospit:. There is, however, a second form of gouty asthma, arising from r* nent lesions and which especially co-exists with emphysema: in recognize here alternate exacerbations and remissio: disappearance and return of articular symptoms. These cases are quite rare : Patissier saw only 2 out of 8 Garrod, 1 out of 40 ; and 1 1 Salter, to whom we owe a treatise on asthma, also repot* in^le case of it. Second. — Some of the ancient writ nty plearifl was probably a simple gouty pleurodynia. Third. — Is there a gouty pneumonia? It has been i some observers, but authenticated cases are yet wanting. Scudam seen gout manifest itself after the disappear;. To-day it certainly has been demonstrated that there h ■ rheummtismal mjdt» meningitis. Two observations a: hier's service furnish irrefragable proof on this point. • Ball : These de Concours pour V Abrogation -'.ft. THE DISEASES OF OLD AGE. 69 question arises whether this be not a fortuitous coincidence. And, accord- ing to the same authority, these two diseases may always coexist without exercising any influence over each other. We shall soon recur to this point. VLT. — Diseases of the urinary passages are quite frequent in gout, and at a certain phase of the disease they become almost the rule. They are, on the contrary, rare in the various forms of chronic articular rheumatism. And herein we discover a characteristic distinction of a not uninteresting nature. It is necessary, however, to eliminate from the domain of visceral gout, in accordance with the rules which we have hitherto followed, everything pertaining to calculi and uric gravel, whether renal or vesical. It is true that these occurrences are frequent among the gouty, but they do not ex- clusively belong to the diathesis. Still, there are urinary diseases traceable directly to gout, and these we shall now describe. A. — The kidneys may suffer a transient functional derangement, present- ing striking analogies with articular gout. This occurs in less advanced periods of the disease, having for its symptoms a sharp but transitory pain, manifestly alternating with articular gout, and which may have its seat in either kidney, accompanied by an albuminuria of short duration. It may be that during the entire course of this conrplication there is no emission of gravel. This is not an exceptional manifestation of gout ; Garrod has observed several examples of it, and I have myself, with Dr. Clin, seen one case. This patient was a physician, and therefore could give descriptions of the phenomena he had experienced, worthy of reliance. B. — Permanent disease of the kidneys becomes almost the rule in •chronic gout ; in this case there is an albuminous nephritis, presenting ana- tomical characteristics which leave no doubt as to their origin, namely, infarctions of urate of soda in the renal parenchyma. We have already described these changes when speaking of pathological anatomy. Once established, gouty albuminous nephritis differs but slightly, in re- spect to symptomatology, from ordinary Bright's disease. The urine is generally found clear and with but little color, containing a var3 T ing, al- though almost always a small quantity of albumen, only a trifling amount of urea and salt, and exhibiting under the microscope fibrinous cylinders, covered with epithelial cells or loaded with granulations. There may be oedema of the face and lower limbs, though this symptom is very frequently absent. As in Bright's disease, so here we find dyspepsia and diarrhoea ; but, as we have already hinted, the progress of the malady is slower and its prognosis less grave than in albuminous nephritis properly so called. Nevertheless, uraemia has sometimes been observed to occur in the course of this disease ; Basham, Todd, Dechamps (of Bordeaux), and other investigators have recorded several examples of it. Some years ago I called attention to this point myself, and Fournier has shown the impor- tance of it in his remarkable these de concours (prize thesis) upon uraemia. C — A vesical gout has been described by various authors : Scudamore speaks of it, and Todd has endeavored to set forth its characteristics ; ' in- deed, a large number of those cases which the English designate by the name of irritable bladder ought to be ascribed to this. ] Todd : Clinical Lectures on Certain Diseases of the Urinary Organs, p. 359. London, 1857. 70 CLINICAL LECTURES ON" At the commencement it is merely a question of a transient affection — precisely as we saw occurring in the case of the kidneys — merely a dynamic derangement, characterized by sudden and violent pain in the bladder, by tenesmus, and by a flow of blood and muco-pus from the urethra, even in the absence of all calculous complications (Todd). These phenomena may alternate with the articular disease. But at a more advanced stage there is a permanent lesion, with catarrh of the bladder and other phenomena of that kind. Professor Laugier was good enough to communicate a case to me proving the reality of vesical gout, independent of all gravel complication. D. — A gouty urethritis, with escape of pus from the urethra, has finally been mentioned ; but have not the writers (Scudaniore in particular) allowed themselves to be imposed upon ? Perhaps it was a case of blennor- rhagic arthritis — such, at least, is the interpretation which may be given to some of Scudamore's observations. Vm — Abarticular — non-visceral — gout. — Independent of the internal diseases that may be developed during the course of gout, there are other manifestations of the same disease, which, though not in-fading ii * organs, are yet localized elsewhere than in the joints : they are seen oc ing the muscles, the nerves, the skin, and some other portions of the economy. A. — In the first group we shall place phenomena of this kind which belong to ligaments, tendons, and fibrous tissue in We have previously established the fact that, when the articular (diar- throdial) cartilages have been saturated with urate of soda, the and tendons are then observed to become impregnated with that a The symptoms of this condition of affairs are generally merged i of articular gout, though they may sometimes plat] pendent role. It is well known, for example, that the fibrous tissue in front of the patella (pre-rotular) may be the seat of pains that are strik analogous to those of acute gout ; this is Bayer s pre mtu Han govt. It n asked, then, if gout can exist in a larval or masked form in tendons and liga- ments ; can it precede, or can it wholly take the place of articular gout \ This is still an obscure point, and one demanding new ill mitigation B. — Muscles.— Gouty subjects frequently experience painful cramps in the muscles of the extremities during an attack of the malady. They suffer very often from lumbago, and may even feel very intense pain points in the chest- wall ; these are* probably in the intercostal musei in the fibrous tissue of the thoracic panetee (gouty pleurodynia). patients very often designate these sensations by the nam. matic 2>ains, although in reality they belong to gout. C ~ Serves.— Pain along* the course of nerve-trunks, partieularlv of the sciatic and trifacial, is also known to be present daring the i -out. Its characteristics are an abrupt appearance and a similar departure, alter- nating with articular' symptoms. T>.— Cutaneous affections.— Brodie and Civiale bug since observed an evident relationship existing between psoriasis, gravel, and uric acid calculi. It is certain that psoriasis may often be met with in those bekmgmfl gouty family, and that it may coexist with gout in one and t indi- vidual. This fact has been placed completelv out of question bv th, servations ; of Holland, Garrod, and Bayer. Eczema has liken . seen to alternate with the most characteristic attacks of goat buch, for the time being, are the only cutaneous diseases whose oomlft- THE DISEASES OF OLD AGE. 71 tion with gout is authentically established. But, under the title arthritides, Bazin and his school have collected a great number of different exanthemata arising from rheumatism and gout, two diseases which they blend into one — arthritis. It must be confessed that the observations they present in support of these opinions are not by any means all that could be desired, and that gout is here left completely in the background. The cases which Bazin collected belong exclusively to rheumatism. E. — Ocular affections. — Morgagni has already described the conjunc- tivitis sometimes occurring in the course of the first attack of gout, and concurrent observations have been made by several authors succeeding him, but of all the ocular diseases associated with gout, the one which de- serves, in the highest degree, to be joined to the diathesis is certainly iritis. Lawrence and Wardrop report cases where the alternation of iritis and distinctly marked gouty attacks could not be called into question ; and Professor Laugier communicated a case to me where this phenomenon was perfectly exhibited. And it is very remarkable indeed to see the iris thus affected in gout, the more so since we know that in articular rheumat- ism and in subacute, nodular and blennorrhagic (gonorrhceal) rheumatism especially, the same symptoms are induced. Lastly, Garrod, in a recent article ' has described a gouty affection of the eye, to which attention had not yet been called — we mean inflammation of the sclerotic, with whitish deposits of urate of soda upon the surface of this structure. F. — Diseases of the auditory apparatus. — We have already dwelt so long upon tophaceous concretions of the external ear, that there is no necessity of again returning to that subject ; and we have likewise pointed out the alterations in the ossicles of the ear. Now, it seems certain to us that pa- tients suffering from chronic gout are liable to become deaf ; and it would be interesting to be able to class this new species of deafness along with the lesions we have just been describing, but as we know nothing posi- tively in this connection, new investigations are necessary to fix our ideas upon this point. Here we shall end the history of abarticular and of visceral gout, and in our next lecture we shall take up some diseases that offer a certain de- gree of relationship to gout. 1 Reynolds : System of Medicine. Art. Gout, by A. B. Garrod. 72 CLINICAL LECTUKES ON LECTURE Till. CONCOMITANT DISEASES OF GOUT. Summary. — Conditions seemingly Allied to the Gouty Diathesis — Uric Anthrax — Grave Phlegmonous Inflammations and Erysipelas — Dry Gangrene — Intercurrent Diseases in Gout — Its Affinity with Diabetes — Greater Of 'jueney < : Relation — Diabetes, Obesity and Gout frequently met with, if not in the Same Individual, at least in Different Members of the Same Family — Observations in Support of this — Practical Results — Gravel — Urinary Concretions — L'ric Acid — Oxalic Acid — Formation of a Uric Acid Sediment not always Proof of Augment- ation in the Secretion of this Acid — Gravel sometimes Associated with the I ence of an Excess of Uric Acid in the Blood — Real or Boppwoi ■ of Gout, Scrofula, and Phthisis; of Gout and Cancer; of Gout and lib- Gentlemen : — At that portion of our course where I thought : ent to give the history of ab-articular B, it would ha \ ture in me to dwell upou certain occurrences which likewis to be more or less directly associated with the gouty diathl - now arrived when it is desirable to Bay I few words con hem. I. — A peculiar predisposition to dangeroufl phlegmonous intlamn. (p. de mauvaise nature) and to Bphace] had long ago bet served in diseases which induce a profound change in the constitution of the blood (crusts). Albuminous nephritis is an example of this kind sipe- las or diffuse phlegmon in regions either inriltr y, or as a result of incision or puncture, is frequently seen to occur in | ing from albuminuria. On this account, punctures and BCarincationa, which in other dropsies are a means of relief, are in thlfl indicated (Rayer). Diabetes offers us a second example of this unfortunate \ tion. English physicians had long since noticed that anthrax, dr\ e and diffuse phlegmon supervened with the utmost readiness in di i jects, and Marchal (de Calvi), unaware of the labors of his pn had the merit of calling attention to this point, which, prior to his time, had scarcely been studied in France. Now we shall give an account of an analogous series of phenomena occurring in the uric acid diathesis and in confirmed gout. This pathological coincidence, which already had been adv scribed by Morgagni, Thompson, Schonlein, Ure, Carmiehael. and 1 in our times been demonstrated through the labors who has concisely divided diabetic symptoms from gout — a work which has been accomplished by none oi 1 Morgagni: De sedib. et causis morborum. lib. iv priori; one 'would be led to imsgi Thus, lead, when exhibited in a medicaments dose to arrest a hemorrh;. produced rapid impregnation of the svstem with this metal, accompai . 1 by the bluish line along the free margin of the gums, and attacks of had- cohc. And , according to Garrod and Price-Jones, mercunj induces sal: The gouty diathesis, by reason of its frequent association with renal diseases is a very serious complication of typhus. I have never seen reo -*- 22^ London 1862 typhus -"- Murchison ; A Tr ^ise on Continued Fever?, etc.. p. eventu. —Schmidtmann : Obser. . Vol. iii , p 370 3r^ e \ : Pra S i ? , S 0bservations on Gout, etc.. p. 87. London, garrod: Reynolds' System, p. 855 1849 SC p d ft?J e : ^ ^ P - *h Day : Disea ^ s of Advanced Lit, tion Y^^ : f ^^ m ^ tla ^^^^,Olm.^S^ K<4 °- l^rry: Collecl 6 Scudamore ': Loc. cit . rrod . 0r , i THE DISEASES OF OLD AGE. 75 tion much more speedily in gout than in other conditions ; ' and I may- add that opium should "be administered with the utmost caution to those subject to chronic gout, when they present any indication of renal disease. In these cases this drug is seen to produce cerebral symptoms out of all proportion to the dose exhibited. 2 Let me point out another interesting fact — one belonging to the same order of ideas — namely, the failure to eliminate turpentine from the uri- nary passages. Hahn (quoted by Guilbert) administered this drug for seventeen months to a gouty patient without causing that characteristic odor of the urine which commonly occurs in similar instances. Was this patient suffering from albuminuria ? 3 IV. — We shall now consider those concomitant diseases of gout which present a more intimate relationship to that affection than those which we have just dwelt upon, and which are more evidently associated with the group of modifications the economy undergoes. Hunter laid it down as a rule, that, when one diathesis invades our or- ganism, no other general disease can exist concurrently with it ; in other words, a constitutional disorder, when once it is established in an individ- ual, admits of no rival. From this principle arose the doctrine of antagonisms — a doctrine un- doubtedly exaggerated by the Viennese school (Rokitansky, Engel), but which, nevertheless, is founded in truth. Still, along with antagonisms, there certainly are affinities; and it is of these relations especially that we desire knowledge and insight. A. — Gout and diabetes. — The idea of a more or less direct connection between diabetes and gout can scarcely be traced back more than two score years. Scudamore, far from suspecting this affinity, holds that these two- diseases arise from distinctly opposite causes. But a German author — Stosch, of Berlin — who published (18*28) "A Treatise on Diabetes," describes therein a metastatic diabetes which occurred after the cessation of gout, and in connection therewith quotes two English writers, Whytt and Fisher. Two years later Neumann records the occurrence of a symptomatic diabetes in gout. 4 At a later period, Prout, who seems to have touched on all questions of this kind, places attacks of gout and rheumatism among the most frequent causes of diabetes. "Nothing is more common," he says, in another place, " than to find a little sugar in the urine of gouty patients, although they remain unconscious of it until the ordinary symptoms of diabetes — poly- uria, thirst, emaciation — openly declare themselves." 5 Another English author, Bence-Jones, has likewise observed that uric acid gravel predisposes- to diabetes. 6 In France, Bayer has frequently remarked to his students the connec- tion subsisting between uric acid gravel, gout, and diabetes. You can con- sult, in this connection, the thesis of M. A. Contour, 7 and the lectures of Claude Bernard. This eminent physiologist has, in fact, stated that dia- 1 Garrod : Loc. cit., p. 354. Price-Jones: Medical Times. Vol. i., p. 66. 1855. 2 Todd : Clinical Lectures on Urinary Diseases, p. 343. 1857. Charcot : Gaz, Medic, Nos. 36, 38, and 39. 3 Guilbert : De la Goutte, p. 100. 1820. 4 Pathologic Vol. vi., p. 607. 5 Prout: Loc. cit., pp. 33, 34. 6 Marchal {de Calvi) : Loc. cit., p. 233. 7 Contour : Theses de Paris, p. 49. 1844. 76 CLINICAL LECTURES OX betes may alternate -with the symptoms of some other disease, and particu- larly with attacks of gout and rheumatism. 1 We had an opportunity ourselves to observe a case which completely confirms the statements of Claude Bernard. A man, fifty-six years of age, who had been suffering from gout for a long time, had succeeded in di- minishing the intensity of the attacks, and finally, in nearly making them disappear altogether, by using — rather say abusing— a specific remedy (liqueur de Laville) ; 2 but, following a slight attack which he promptly re- pressed, appeared thirst, polyuria, increased appetite, emaciation, weakness, and the other characteristic phenomena of diabetes. "When this patient consulted us for the first time, the urine contained a considerable quantity of sugar. An appropriate diet continued for over a year produced a marked improvement in his condition, though, the diabetes having considerably diminished, a few mild attacks of gout reappeared. Marchal (de Calui) has likewise been engaged in discussing the affinity between these various diseases, as regards diabetic gangrene, since 1866. Some time later he published a work where this subject is treated with re- markable ability. 3 According to this distinguished author, there is a uric acid or gouty diabetes, and this conclusion is in conformity with previous observations, and with absolute reality. But Marchal (de Calci) may be accused per- haps of having extended the domain of this form of diabetes too far, and, indeed, that of the uric acid diathesis in general. The considerations which he presents in this respect are hardly applicable, in France at least, to any but the favored class of society. It cannot be questioned but that an affinity exists between diabetes on the one hand, and gout and uric acid gravel on the other ; although the fre- quency of this relationship varies according to the kind of people in whom we observe the occurrences. In this way Griesinger who has studied diabetes among all classes of society, found gout in three out of two h • and twenty-five diabetic subjects; 4 Dr. Seegen, on the contrary, practising medicine at the springs of Carlsbad, and where the patients consequently belong to the higher walks of life, met with three cases of gout among twenty-one diabetic individuals. The proportion is thus seen to vary from one-tenth to one-seventy-fifth. 5 Nevertheless, we must not be restricted to the registration of where gout is transformed into diabetes in the same individual ; but the hereditary transmission of symptoms must likewise be studied, and also their distribution among different members of the same family, as in the case of diseases of the nervous system, where this method has met with so much success. It is very rare to find gout and confirmed diabetes coexisting in the same individual ; but these two diseases alternate with and other. Uric acid gravel or gout opens the scene ; and then, usually, gout 1 Lemons de Physiologie Experimental, etc, p. 436. 18oo : "Diabetes alter- nants." _ 2 Dr. Laville's anti-gout liquid and pills. Active principle of liquid probablv vora- tna— certainly a powerful remedy or poison ; teaspoonful in water. Pills I I •of soda and physalin ; two a day with meals. Shorten attacks at expense of he'alth. — L. H. H. 3 L'Union Medicate, No. 29. 185(3. Recherches sur les Accidents Diabetiques, etc : loc. at, pp. 409, 469. 1864. ^Griesinger : Studien liber Diabetes. Arcbiv fur phvsiol. Heilkunde, p. It. « P. Seegen : Beitriige zur Casuistick des Meliturie. Yirchow's Archiv. VoL xxi. , Vol. xxx. 1864. * THE DISEASES OP OLD AGE. 77 vanishes the moment diabetes makes its appearance. Rayer had already observed that gout changed into diabetes, and Garrod says in these very words : " Gout stops ivhen diabetes appears." ' Let me add that obesity frequently precedes the development of gout. In cases such as those to which we have just alluded, the prognosis is sometimes as grave as in ordinary diabetes, and phthisis pulmonalis and symptoms of gangrene suddenly occur. Still it must be acknowledged that gouty diabetes is in general relatively benignant, especially if the patient follow a suitable diet. Then it is that diabetes is latent (Prout). I might cite cases where a cure seemed to coincide with a return of gravel or gout, and this caused Prout to say that the appearance of uric acid gravel in dia- betes is a favorable sign ; 2 nevertheless, these two diseases may coexist and yet not mutually improve. We shall now regard the analogy between gout and diabetes, consid- ered in a family composed of several members ; and thus we notice a father who is gouty, diabetic, and phthisical, beget a gouty son (Billard de Corbi- gny 3 ) ; or, again, a diabetic father have a gouty son (personal observation). We had an opportunity, ourselves to witness a very remarkable case of this kind, which Dr. Real communicated to us, and where gout, scrofula, diabetes, and obesity were seen manifesting themselves in the majority of the members of the same family. This observation is here reduced to tabular form : Table I. Father, brewer, distiller. . . Mother First son, brewer Second son, brewer Third son Fourth son, alcoholic habits Fifth son A daughter Daughter of the latter. A colossus. Lymphatic Sciatica. Scrofula, ' Articular | „ Keratitis rheumatism, f ; UDesu y- Diabetes. Died ptliisical (48 years old). Diabetes at 50 J S Gout at 25 Obesity at 35 Diabetes . Lymphatic Gout at 30 Obesity Diabetes. Obesity . . Keratitis . . Gout Obesity at 35 Gout Obesity Gout Obesity Diabetes . old). Died in delirium. Died of an accident. Died of cirrhosis. Died phthisical (48' years old). Still living. Still living. There is evidently a more or less intimate connection between these dif- ferent diseases which are thus reproduced, in various degrees, in all the members of the same family ; and I have noticed the following combina- tion : Table II. Gouty father . f First son — gravel. 1 Second son — diabetes | Third son — gout ^ Daughter — ; Examples of this kind could easily be multiplied, but I think enough A. B. Garrod: Reynolds' System of Medicine. Vol. i., p. 825. London, 18G6. See : Gulstonian Lectures on Diabetes, in the British Journal, p. 319. 1878. Loc. cat., p. 25. » Gaz. des Hopitaux, p. 212. 1852. 78 CLINICAL LECTUKES OX has been said to show you that there is a correlation between the uric acid diathesis, diabetes, and gout, which is governed by laws as yet unknown. It is easy to appreciate what are the practical deductions from these data. The urine of the gouty must, necessarily, be carefully examined ; and when this particular variety of diabetes shall have been recognized, a method of treatment must be established in accordance with its origin. B. — Gout and gravel. — The uric acid diathesis includes gout in all its aspects, and hence it is not surprising that gravel, so often a manifestation of the diathesis, should very frequently be met with in goutv pati* The bond which unites these two diseases has been act • «1 in all times. "You have gravel and I have gout," wrote Moms, "we have espoused two sist- lenham, Murray and Morgl described this affinity, which seems to us beyond all dispute. Still there is, at the same time, a certain ai conditions ; it is rare, indeed, to meet them simultaneously, for thev rather tend to succeed each other in alternation. Tin- moei is for gravel to precede gout and to diss] D the Utt but the converse may be observed, and in some cast - appears when gravel is established. I once witness. md. Besides, when gout and grave] coexist is oee, as is too often the case, that they are simul- frequently accumulates for a long time in t; from the organ, thus giving rise to the Bjmpfa It is important to notice that the chemii cretions is not always the same ii. urate of ammonia may also be pn Bent, and of oxalate of lime. And oxalic gravel is lik* gravel, since uric acid, as you know, may 1>. urea, allanto'm, and oxalic acid. These variations in the nature of nrinar In those gouty patients subject to calculus." the concretions formed of concentric 1 which m oxalates were alternately deposited, thus clearly \ successively occurred in the composition of 1 1 Finally, let me remark that that the blood, sweat and urine of gouty subjects. 5 at | gravel manifests itself —another proof of the these different morbid phenomena. I think, however, that it should be mentioned here that : in the urine, a short time after its emifi amorphous mates or uric acid in the crystalli prove that the excretion of this acid is absolutely i diminution in the watery part of the urine and are sumcient conditions for inducing precipitation of I out any real increase in the amount of uric acid. ( I we know to-day, thanks to the labor of Bart, Is.' that in reserves pertect limpidity for a long time after its emission m ableproportion of uric acid. To know the trm m 1 Scudamore : Loc. cit, p. 531 Hxarrod : On Gout. Loc. cit p 187 THE DISEASES OF OLD AGE. 79 such a case, it is indispensable to analyze the total amount of urine passed during the twenty-four hours, and even to repeat this examination for the five or six days succeeding, according to the teachings of Parkes and Banke ; ' for it has been proved that the excretion of uric acid undergoes the most marked variations, not only at different periods of the same day, but also from one day to another. It seems, however, very reasonable to admit that uric acid exists in the blood in excess, when urinary sediments form, not after, but before emis- sion ; and still more so when gravel is present. But this occurrence may be induced by causes entirely independent of the uric acid diathesis, a purely local inflammation of the urinary apparatus sufficing for its pro- duction (Brodie, Rayer). 2 More than once I have had an opportunity to discover a complete absence of uric acid in the serum of the blood of non- gouty individuals who habitually passed uric concretions of larger or smaller size during the act of micturition. Still, I do not mean to absolutely deny a correlation between these two orders of occurrences. Far from it— for it is established that gravel, in certain patients, arises from the presence of an excess of uric acid in the blood. Dr. Ball communicated a case to me where a man, sixty -four years of age, frequently passed small uric calculi after a violent attack of renal colic. A blister having been applied to the epigastric region, it was found that the serous fluid obtained in this manner contained a considerable quantity of uric acid. This patient, however, had never had any of the symptoms of articular gout, and had no albuminuria. This case must un- doubtedly be associated with those where gravel is seen to precede the occurrence of gout, and thereafter to alternate with this disease. Indeed, we can make three classes in this connection. Sometimes gravel precedes gout ; this is most frequently the case. Sometimes it follows it ; this more rarely occurs. And again, rarest of all, these two conditions coincide. In five hundred cases of gout, Scudamore met with only five who had calculi : and Brodie claims never to have seen gravel in a gouty patient who had tophaceous concretions or chalk-stones. The symptoms resulting from gravel commingle with those of gout. There may be emission of fine gravel with the urine, and a transient albu- minuria ; there ma}' be renal gravel, which Rayer describes under the name of gouty nephritis ; but we know there exists another form of gouty ne- phritis characterized by deposits of urate of soda in the parenchyma of the kidney (the English authors' gouty kidney). Finally, ischuria maybe pres- ent hi the gouty, and renal colics, gouty pyelitis, and irritability of the bladder may occur. All these phenomena which may coexist with gravel, are not necessarily the results of it, but, as we have previously seen, they all may simulate that condition. C. — Gout, scrofula, and phthisis. — Does there exist, then, a real connec- tion between gout, scrofula, and phthisis ? We are little disposed to affirm this absolutely, but it is true that scrofula is frequent in those subject to nodular rheumatism. We may then question whether we ought not to as- sign to this latter affection what was attributed to gout. But Prout, who has carefully studied this point, admits that scrofula and gout are frequently associated, and that the children of gouty parents are predisposed to phthi- 1 Parkes: On Urine, p. 218. London, 1860. Ranke : Ausscheidung der Harnsaure. Miinchen, 1858. '-' Lemons sur les Maladies des Organes Urinaires. Transl. by Patron, pp. 251, 278. Paris, 1745. Maladies des Reins. Vol. I., pp. 94, 197, 198. Paris, 1839. 80 CLINICAL LECTURES OX sis. 1 This latter disease, quite rare in acute articular rheumatism (Wun- derlich, Hamernjk *), is frequent in patients who have chronic articular rheu- matism, while in gout, on the other hand, it rarely occurs, although diabetes, whose close relationship to gout we have just described, is. as it were, an ever open gate for the entrance of phthisis. Garrod, however, saw phthisis develop and run a rapid course in a young man who had tophaceous con- cretions around several joints ; but this ought to be regarded as an excep- tional case. 3 D. — Gout and cancer. — Does gout exclude cancerous affections? Or, on the other hand, does it favor their development ? My former teacher and predecessor in the v ,. be- lieved in the existence of a close connection between these two diatheses. For myself, I can affirm as a certainty, that in nodular rhi cer and cancroid growths are not exceptions] J had an opportunity of meeting examples of it in esses of gout, but Bayer describes the existence of both t the same individual, at least in the same fainik ise published some years ago in an English journal * proves thai these united in the same person. It w cer- cells in the lungs and liver, occurring in years old, who had largi acteristic infarctions of urate of soda in tl sufficient to demonstrate that at 1< uA w i tween gout and cancer. E. — Gout and rheumatim rheumatism and gout have led many obstnrvi proclaim the identity of these two disessi B. We shall to give an opinion upon this point when we shall h and hence we reserve this discussion for anon 1 Prout: Loc. cit, p, 408. 5 Wunderlich : Patholo^. und Therapie. Bd. iv.. p 3 Garrod: On Gout, p. < Biidd : Lancet, p 492. 1851 THE DISEASES OF OLD AGE. 81 LECTUKE IX. ETIOLOGY OF GOUT. Summary. — Study of the Conditions which Govern the Development of Gout — Suita- ble Method to follow in Making this Kind of Investigation — Inconvenience of the Premature Intervention of Chemical and Physiological Theories — Necessity of Separating Acquired Facts from the Hypotheses which have been advanced as Ap- plicable to them — Historical Pathology of Gout — Antiquity of this Disease — Wri- ters who have Described its Existence — Diminution of Gout in Modern Times — Permanence of its Characteristics — Modifications arising from our Hygienic Habits and their Probable Consequences — Medical Geography of Gout — Its Resi- dence especially in England and in London — Met with, however, to a less Ex- tent in some other Countries — Almost wholly Disappears in Hot Climes — Analyti- cal Study of the Causes of Gout — Causes in the Individual : Spontaneity— Heredity — Sex — Age — Temperament, Constitution — Hygienic Causes : Climate — Over- eating, Want of Exercise — Intellectual Work — Venereal Excesses — Fermented Liquors: Ale, Porter, Wine, and Cider — Exciting Causes. .leuilLv. — English Beers. Gentlemen : — Hitherto we have studied gout in relation to the lesions which accompany the symptoms which characterize, and the affinities which bind it to other discuses. There now remains for us to seek the conditions presiding over its development ; we shall therefore, in a few words, point out the method we purpose to follow in the course of our investigations. We shall first begin with the empirical study of facts furnished us by direct observation, outside of all theoretical prejudices. Then we shall endeavor to interpret these data from the standpoint of modern physi- ology ; in other words, we shall try to follow, in their successive develop- ment, the modifications which the organism may undergo through the influence of those causes from which experience teaches us gout arises. Afterward it will be necessary to ask ourselves how the changes thus oc- curring in the economy can induce the various phenomena that make up the clinical history of this disease ; in a word,- we shall endeavor to obtain an idea of the pathological physiology of gout. And this is the crowning work in all nosological study. It must be acknowledged, however, that the rigorous and systematic separation of the two standpoints we have just described is far more requi- site in the question we are discussing ; for it is here, especially, that the premature and rash intervention of chemical and physiological theories to account for the morbid phenomena, may tend to bring this kind of study into unmerited discredit. He who shall succeed in harmonizing the pathology of the ancients and the physiology of the moderns, will surely, says Boerhaave, deserve the highest praise. 1 But modern physiology in Boerhaave's time scarcely cor- 1 Nee in medicura plus laudis redundare posset, quam ex eo labore, quo veterura pathologiam redigeret ad neotericoruni pkysiollfiam. — Boerhaave: Med. Stud. Medic. Pars, ix., Pathologia, p. ol'o. 6 82 CLI1S1CAL LECTURES OX responds to the science as we understand it to-day ; and so, in the coming centuries, may contemporaneous physiology likewise become as obsolete in its turn. Hence, we must use the utmost reserve, and advance along thi3 path only after infinite precautions ; for what our predecessors lacked was not an appreciation of the important role which physiology plays in medi- cal studies, but broader and more exact notions concerning those diffi- cult problems they sometimes attempted to solve without having first measured their extent. Indeed, it must be acknowledged that the history of the products of disassimilation still remains obscure, notwithstanding the progress we have made in the study of the nutritive functions ; and uric acid, especially, is no exception to this rule. "We know very little concerning the conditions which preside over its regular formation, and the pathological circum- stances that may modify it. Thus, at the very commencement it is easy to foresee that the pathogenesis of the uric acid diathesis is still in a rudi- mentary condition, and that, consequently, at the present time it is iinpossi- sible for a complete theory of gout to be drawn up ; at the utmost we are only permitted to place a landmark here and there, which may, perhaps, serve to direct the investigations of those who come after us. We shall begin this analysis with a rapid glance over the history and the geography of gout, for, since we are concerned here with a constitutional disease, and one essentially arising from the general state of the individual, it is absolutely necessary to study in order that we may obtain a linn grasp on its characteristics, the climatic and social conditions which, collectively, seem to predispose the human species to this malady. To regard ad. in this light is to construct its etiology on a grand scale. I. — Historical Pathology of Gout. To recount the vicissitudes which diseases have experienced in the course of centuries, and to search in history for the causes of these changes— this is the chief aim of historical pathology ; and besides, h. ns of this kind enable us not only to appreciate the pathogenic influence of external causes, but also the results of the inherent conditions of man himfi But, in order that it may be possible to apply this process to the study of a disease, the attention of our predecessors must have long since been called thereto ; and it is only in these cases that one may hope to g an ample harvest from historical documents. Now. similar conditio: rarely realized, except in the case of epidemic d which used t duce such terrible ravages — and of certain chronic affections which, in all times, have attracted the notice of investigators. A few examples will en- able you to readily grasp my idea. The plague, so formidable in times, appeared, for the last time in France, at the beginning of th« vious century (1721); it is tending, also, to become extinct in ti countries which have always been its principal centres. One may. then, with reason* demand what the conditions were which, in past tin:< - its development, and which to-day seem to have ci was still extant in Martigues at the end of the last century, but sine, epoch it has disappeared from French soil ; it is becoming r in Europe, tending to take refuge in Norway, as the gout does ii land. We can readily undersiafl how much attraction i phic physician the history of an almost extinct disease may hai THE DISEASES OF OLD AGE. 83 has played so great a part and occupied such a prominent position in the minds of legislators of every century. J Among the diseases whose historical study offers a truly scientific in- terest, gout clearly stands in the first rank ; indeed, it is certain that thi3 disease used to prevail in a somewhat epidemic manner among the more favored classes of society. To-day it is seen gradually to become extinct, although it has not undergone any change in its symptomatic development since the most remote epochs, inasmuch as we find it completely described in the works of the ancients. We shall now give you a succinct statement of the principal data fur- nished us by history for the solving of this question. Antiquity of Gout. There is no doubt but that gout has been known in Europe since the days of remotest antiquity ; the writings of Hippocrates are proof of this. But it is in the reign of the first Caesars that it seems to have reached its culmination ; and in this connection we possess unexampled accounts that leave nothing to be desired. The writings of physicians, the works of his- torians, the satires of poets — all are filled with allusions to this malady. In the first century of the Christian era, Aretaeus and Celsus on the one hand, and Ovid and Seneca on the other, have given ample information concerning the pathological condition of the Roman people in this regard. In the second century, Galen (130 a.d.) and the interesting dialogues of Lucian of Samosata 2 furnish us with details valuable both from a hygienic and a medical standpoint. In the third century an edict of Diocletian ex- empts gouty subjects from public services when they are attacked with articular deformities great enough to interfere with the exercise of the ordinary functions of life, a circumstance which seems to prove both the extreme frequency of gout at that period, and the immutability of the chief symptomatic characteristics of this disease. From the third to the sixth century things seem to have remained un- altered, if we may judge from the writings of Oribasius (326-403 a.d.), Alexander of Tralles (525-605 a.d), Aetius, Paulus of iEgina (660 a.d.) and many other physicians. In the middle ages the Arabians, continuing the medical traditions of antiquity, inform us that gout has lost scarcely any ground since that epoch 3 ; and the authors of the Lower Empire (Byzan- tine), Actuarius, Demetrius Pepagomnenus, etc, carry us up to the thirteenth century. Modern times being reached, we find ourselves confronted by 1 The stringent measures which inflicted upon the leper an absolute isolation from all society were maintained with unrelaxed severity during the middle ages. They may have contributed to the extinction of leprosy. Certain pathologists prefer to in- voke, in these cases, a morbid spontaneity, and we willingly accept the term, provided it be thoroughly understood that it prejudges in nowise the real gist of the question, and only serves to express a gap in our knowledge. 2 Tragodopodogra; Okupous the Fleet-footed. The latter poem, according to some critics, should not be attributed to Lucian. Okupous, one of Homer's names for Achdles.— L. H. H. 3 It must not be forgotten, however, that the information offered by the authors of that period is not always worthy of absolute trust. Too often they copy from one another, without thinking of collecting personal observations. The Arabians, espe- cially, have borrowed largely from Greek medical literature ; and as gout is fre- quently discovered in the works of the ancients, they certainly appropriated a consid- erable part of their labors. 84 CLINICAL LECTURES ON innumerable evidences that leave no doubt as to the general diffusion of gout over Europe. And thus, gentlemen, you see an uninterrupted chain of historical proofs testifying that for more than twenty centuries this disease has held sway in the countries we now inhabit. But to-day we need only glance around us in order to convince ourselves that gout is becoming rarer and rarer ; and here it is proper to enter into a few details. DrviiNunoN of Gout in Modern Times. This retrograde movement of gout seems especially to have manifested itself since the beginning of the present century. Documents collected by Corradi ' inform us that even in England this disease is diminishing in fre- quency, according to Owen and Fuller ; that it 1ms markedly declined in Holland, according to Coley ; and also in Switzerland, according to Pro- fessor Lebert. It has almost disappeared from those localities where it used to prevail, for in our time it is scarcely ever met with in Rome or Constantinople. In this respect it is evident that the state of afiair- undergone considerable change. And this, undoubtedly, is the reason the works which have appeared upon this subject within the are so few in number ; for, save in England, materials for new investiga- tions in gout are very rarely obtained from observation. In spite of its decadence, however, this d baa undergone no change in its symptomatic developments, as you will soon see. Permanence of the Characteristics of Gout. We have only to compare the descriptions bequeathed to us by antiquity with those found in modern works, to convince our . clini- cal standpoint, gout has always remained true to its primitive type. Oku- pous the fleet-footed 12 completely n in this respect) the cases observed by Van Swieten, sixteen hundred years Liter. Concerning the etiology, we are always confronted by the same con- ditions. Suetonius called gout mfifbua domxnorum, and B m has expressed the same idea in slightly different terms As for the mi! exercised upon the development of this .s has always figured in the universally accepted class of traditie: And finally, let us add that the Greek and Roman pi who described the characteristics of gout so concisely, barely mentioned the existence of articular rheumatism ; so that many authors consider it a new disease, or at least as one almost unknown in ancr 1 This is the opinion of Sydenham, reiterated later on by Hecker and Leupoldt.' Farther on we shall have an opportunity to prove to you. by nnei tionable evidence, that there is much exaggeration in this way of looking at it, and that rheumatism most certainly existed among tbl of antiquity ; but in this case there was Barely quite trust, and one which suffices, at all events, to show that the general physiognomy of gout has never varied. } Delia odieraa diminuzione della podojra. etc.. del Di so Corradi. Bologna, I860. > Hecker: Rede uber die anfeinandei Folge der Dyakraaten. - einzeit, 1837. Leupoldt: Geschichte der Mcdiciu.. p THE DISEASES OF OLD AGE. 85 What deductions may we draw from the facts we have just set forth ? Shall we admit, with Corradi, that the decadence of gout results from mod- eration in our customs and from a better alimentary hygiene ? There cer- tainly has been a great change in our habits in this respect. The suppers of Lucullus have disappeared for many a century ; we no longer possess the heroic appetites of the doughty knights of the middle ages ; nor is it the fashion to-day to gather, as at the feasts of the Burgraves, " Autour d'un boeuf entier, servi sur un plat d'or." l "We are accustomed to a less abundant diet, to one consisting less ex- clusively of animal food, and our repasts are not so prolonged ; besides, the abuse of fermented drinks has considerably diminished, even in England, where the customs of the last century left much to be desired in this respect IL — Medical Geography of Gout. Medical geography is, equally with historical pathology, one of the most fruitful means of investigation in etiological research. It enables us to become acquainted with the different regions of the globe in which certain diseases prevail, and thus allows upon the grandest scale, a study of the cosmical, tellurial, and even anthropological conditions that may favor or hinder their development Concerning gout in particular, geography teaches us that to-day it only exists upon one spot of our globe in the condition of a generally diffused malady : this, of course, is in England. Here, however, England proper is meant, for neither Ireland nor Scotland is in the same position, in this regard, as the southern portion of the United Kingdom. Besides, it is in London especially that the predominance of gout is shown : in that city it prevails, not only among the best classes of society, but even among the body of the people and working-classes least favored in respect to the necessaries of life. We shall endeavor, farther on, to explain the reason of this singular choice of habitation. We will merely say, for the time being, that gout exists in other parts of the globe, though in a very much less degree. It is met with in some portions of France, especially Lorraine and Normandy, the provinces which have in all times been noted for their good fare. It is likewise present in Germany, and in countries where beer is the ordinary beverage of the population. It is certain, moreover, that this disease is only prevalent in the tem- perate regions of the earth. Near the equator and in the tropics, gout is hardly known ; in India it sometimes attacks Englishmen, though less fre- quently than in their native country, while it spares the indigenous popu- lation. In Egypt it only attacks the Europeans and those comfortably conditioned Turks who set at naught the precepts of the Koran ; but the fellahs seem to enjoy absolute immunity. Finally, in Brazil they hardly know what gout is, although the diet of the inhabitants is very highly animal (Dundas). I have taken most of these details from Dr. Hirsch, of Berlin, who has published an excellent work upon this subject. 2 Climate has a most obvious influence here : it is not a question of race, for the negroes in the English army, when placed under the same conditions j» — 1 Around a tvhole ox, served up on a golden dish. 2 Handbuch der historisch-geogr. Pathologie. Erlangen, 1859. 86 CLINICAL LECTUEES ON as the whites, are, like the latter, liable to contract gout ; this seems to be proved by some observations reported by Quarrier. 1 Articular rheumatism behaves in a very different fashion in the above respect : it appears to exist in all climates, being often met with in India in the acute, as well as the chronic form : indeed, to use an expression of Mtihry's, rheumatism is an ubiquitous disease. 2 Here is a striking differ- ence between these two analogous diseases ; and one which it is important to point out. We have only sketched the most salient points of the pathological his- torj and medical geography of gout. Now, however, we must abandon this " straightforward " method of study, descending from the very general standpoint we have taken in order to engage in the minute analysis of those particular circumstances which may give rise to this disease. In the course of this study we shall have an opportunity to point out facts that are still but little known in France, and which, in every respect, merit your attention. ANALYTICAL STUDY OF THE CAUSES OF GOUT. I. — Causes whose Sevt is in the Individual, A. — Spontaneity. — It is a point beyond dispute that gout can develop spontaneously; facts adduced by all authors prove it, and I have m met with such cases. There reside, then, in the very constitution of some individuals, conditions which are favorable to the development of gout, and external circumstances do nothing but bring out the disease. In this there is nothing that should astonish you : for an excessive production, or a faulty elimination of uric acid seems to be the fundamental condition f gouty diathesis. We find uric acid a normal ingredient in the circulatory fluid, and for ever so slight an increase in this quantity, the whole train of pathological changes may be displayed. B. — Heredity. — The definition of gout as expressed by modern writers always entails the idea of heredity. Physicians who collect observations from hospitals have already established the truth concerning tins point, namely, the frequency of hereditary transmission; and in private practice this influence of heredity is recognized i. I shall submit a few sta- tistics to you, which may impart an approximate idea of the importance of this condition. Scudamore met with heredity in 309 out of 523 cases, or in a little over fifty-nine per cent. Patissier {reports) 34 times in 80 cases, or in more than forty-two cent. And Garrod in 50 out of 100 cases, or in one-half. Hereditary gout often develops quite early, and before the time usually happens from other causes. Now. ordinarily, gout of a spontane- ous origin makes itself manifest between the thirtieth' and the thirty-fifth years of life ; but hereditary gout does not wait so long a tin* ing itself. It often makes its appearance at one definite age in each l ber of the same family. Garrod records a case where, in one of the . J Edinburgh Med. and Surof. Jonm Vol. ii.. p. 451 -Klimatoiogisohe Vutersuchuugeu. p. 818, I THE DISEASES OF OLD AGE. 87 English families, the eldest son was attacked with gout the day he received the ancestral heritage; and, moreover, this succession was perpetuated dur- ing four centuries. C. — Sex. — The influence of sex upon the production of gout is not less evident than that of heredity. In this respect women enjoy a comparative immunity impossible to deny. Of the eighty cases collected by Patissier, there were only two belonging to the female sex. It is at the time of the menopause that these phenomena occur — a fact observed by Hippocrates. Now, as we shall soon see, chronic rheumatism essentially differs from gout in this regard. There are, however, exceptions to the rule, and women are sometimes seen to become subjects of gout quite early in life ; but here we will almost always recognize the influence of heredity. Finally, let us add that it is the asthenic form of the disease, especially, that prevails in the female sex. D. — Age. — From the thirtieth to the thirty-fifth year of life is, accord- ing to Scudamore, the classical age for gout. It is very rarely seen before the twentieth, or after the sixtieth year. Garrod, however, met with it once in a nine-year old patient, and once in a young man under seventeen years of age. He also reports a few cases where this disease was developed in men from sixty to seventy years old. Kheumatism, on the other hand, appears earlier, and is generally ob- served before the age of thirty-five. E. — Temperament, constitution. — It has frequently been attempted to collect together characteristics of a special constitution predisposing to gout ; but the study of facts tells us that it respects no temperament, and may develop in the feeble as well as in the most vigorous constitutions. The type of the disease, however, is modified by the general state of the organism ; the sthenic form occurs especially in the sanguine and plethoric, while the asthenic variety is met with in women and those of a nervous temperament. H. — Let us forego, now, the further study of the causes residing in the individual, to consider those resulting from his surrounding circumstances, first discussing hygiene, and especially alimentation, since in this way we shall obtain valuable data for the solution of the problem we are endeavor- ing to elucidate. A. — Climate. — Medical geography has already demonstrated that gout belongs solely to the temperate regions of the earth, to all appearances avoiding the tropics. Unknown in Brazil, Africa, and the equatorial re- gions, it sometimes, however, attacks those Europeans who continue the habits of a cold climate while residing in a hot country ; and this is why the English in East India are often liable to be attacked with it. B. — Excess in eating and want of exercise — It has always been recognized that too nourishing a diet and too idle a life — two causes frequently acting in concert — directly predispose to gouty manifestations ; and this is un- doubtedly the reason why it prevails among the higher classes, and is less frequently met with among the masses. This is familiarly expressed by saying that gout proceeds from an excess of receipts over expenses. We shall soon see that facts do not sustain such a simple interpretation ae the above ; it is, at least, certain that a diet consisting of too much animal food favors the development of this malady, and that large eaters are frequently among the number of its subjects. C. — Influence of the nervous system. — We may no longer 'deny the influ- ence exercised by cerebral causes ; and intellectual labor, moral emotion, S8 CLINICAL LECTURES ON - and intensity of thought have always occupied an important position in the etiology of gout. This justified the witty mot with which Sydenham con- soled himself for being a sufferer from gout : " Livites interemit ptures quam pauper es, plures sapientes quam fatuos," are the words he uses in speaking of this disease. 1 It is indisputable that the most distinguished political characters in England, at least, were martyrs to this affection ; we may cite, among others, the case of the two Pitts. The first of these two great min- isters — the Earl of Chatham — was known to be no worshipper of Bacchus ; while the same cannot be as truly said of his son, William Pitt, who never spoke in the House of Commons without having first fired his eloquence with copious libations. D. — Venereal excesses. — Abuse of venery may clearly act in an unfavor- able manner upon gout, on account of the perturbation of the nervous system which results from it. But we have recourse here to a much sim- pler explanation : it is well known that excesses of this sort are closely connected with the carouses succeeding feasts, and it is to the co-operation of the latter occurrence, perhaps, that we must here assign the principal role. Two other causes remain to demand our attention ; I refer to the influ- ence of fermented drinks and of saturnine poisoning. The action of fermented liquors is so evident, that Garrod has well said: "Man, deprived of these beverages, would never have known the gout." The province of lead-poisoning is, in this respect, much more limited ; but, from a standpoint of pathogenesis, this aspect of the question is of the deepest interest. We shall consider, in order, these two classes of phenomena. E. — Fermented liquors. — From our point of view, we must make a radical distinction between spirituous liquors (rum, brandy, whisker etc.) — liquors which contain from forty to seventy parts of alcohol in one hundred — and the simple fermented beverages (wine, beer, cider, etc.), whose alcoholic strength varies from four to twenty per cent. At the first glance it looks as though the more a liquor is charged with alcohol, the more it predisposes to gout ; but such is not the fact, and you will I tonished to learn that the use — even the abuse— of distilled liquor does not seem to exercise the slightest influence in this respect. In is hardly ever met with among people who drink brandy, h where alcoholismus is so frequent — according to Magnus Huss — this d is out of the question ; and it is the same in Denmark, Russia, and Poland. In Scotland and Ireland, gout is rare among the lower classes. In Kdin- burgh, with a large hospital practice, Bennett 3 and Christison met with barely more than one or two cases of it. Xow, in these countries, the only alcoholic liquor which the people drink is whiskey. In London, on the other hand, gout is a very common disease among the working classes, and is frequently met with in the hospitals. Now, the only fundamental difference that can possibly be established, in tl spect, between the northern and the central portions of the United King- dom, is the enormous consumption of strong beer (ale, stout, and porter) by the laborers who live in the metropolis. 3 1 It kills the rich oftener than the poor, the wise man oftener than the fool. Clinical Lectures, etc., by J. Hughes Bennett Second edition, p. Dili. Edin- burgh, 185S.— L. H. H. 3 See Appendix, inserted at the close of this lecture. TIIE DISEASES OF OLD AGE. 89 This truly remarkable influence of these beverages lias been recognized by all English writers on the subject, commencing with Scudamore. He tells us that " gout is much more frequent in London, among the masses, since the use of porter has become habitual." The testimony of Watson, Budd, and Todd also corroborates this assertion : " Most of those who are given to the use of beer, especially porter, sooner or later suffer from gout," says the last-named of these three authors. An example borrowed from Budd * will illustrate the influence which this kind of liquor exercises. There is, in London, a body of laborers who work at the raising of ballast from the bottom of the Thames. This is done during low tide, and consequently, the working hours fall sometimes during the day-time, and at other times at night. The workmen, who are exposed to all sorts of inclemencies, are also obliged to expend great mus- cular effort ; and, in order to obtain the best return (please to notice here the practical nature of the English), a large allowance of porter is given to these men. Each one drinks two or three gallons a day ; and, apart from this enormous consumption of fluid, their diet is that of the very lowest classes in London. Now, gout is an exceptionally frequent disease among these poor men, who share this sorry privilege with the peers of the realm ; and although their numbers are but very few, many of them are each year admitted as gouty subjects in the Seamen's Hospital. And yet, these are generally unfortunate Irish peasants, in whom an hereditary vice of constitution could not be advanced as a cause. Garrod, on his side, attained the same results. He states that the em- ployes of large breweries are frequently attacked with the gout, and yet nothing can be found in their antecedents to explain this morbid predis- position, except it be the abuse of ale, and porter especially. These two beverages, however, are not remarkable for their richness in alcohol ; according to Mulder, Scotch ale contains eight per cent, of alcohol, and porter five per cent. a This proportion is smaller than that in our French wines, and does not exceed that of the German beers, which seldom pro- duce such effects, in spite of the large amounts drunk in the breweries. It is evident, consequently, that d priori reasoning cannot be applied to the question we are discussing, and that the influence of fermented drinks upon gout is far from corresponding to their percentage of alcohol. Cir- cumstances of a different kind, which have escaped us to this day, probably interpose themselves at this point ; and for every kind of liquor we must have recourse to the data of direct experimentation. We shall now consider the action of wine. The first rank must here be conferred upon the spirituous wines (Port, Sherry, Madeira, Marsala), which are so extensively used in England, in all classes of society. These contain a considerable quantity of alcohol, varying from seventeen to twenty per cent. The lighter wines (Ehine, Moselle, Bordeaux, Champagne) are far from exercising the same influence as the former class. But we cannot say the same of Burgundy, which nevertheless, contains scarcely more alcohol than the preceding. " Red Hermitage and Burgundy, the latter especially," Scudamore says, " contain gout in every glass." 1 Tweedie : Library of Medicine. Vol. v., Art. Gout. Also in Bennett's (J. Hughes) Clinical Lectures, etc., p. 992. Edinburgh, 1868.— L. H. H. 2 Mulder : De la Biere. Trad. Delondre, p. 327. Paris, 1861. 90 CLINICAL LECTUPwES ON Even cider, that beverage seemingly so free from danger, also appears to favor the development of gout. According to Garrod, it is soft | cider, and that having undergone only partial fermentation, which possesses this unpleasant property. I think that, as the influence which certain beverages exercise in this regard has been sufficiently well proved, we may now safely pass to the consideration of another subject. B. — Lead-poisoning. — Garrod states that out of fifty-one gouty patients who were in his service at the hospital, no less than sixteen were painters or plumbers by trade ; and subsequent researches only confirm this strange result. Thus, saturnine impregnation has been ranked among the predis- posing causes of gout. This coincidence once pointed out, documents in its support flowed in from all quarters. Among the authors anterior to Garrod, Musgrave may be cited as one who noticed gout following lead-colic, Falconer as another making the same observation, and Parry, who, in his collection of cases, has shown that gout is frequent in those attacked with lead-paralysis. Finally, Todd reports several cases of gout occurring under analogous cir- cumstances. 1 Since the publication of Garrod's work, several English authors have described cases of this kind ; we may especially cite Burrows and Begbie." But in England we must take into account those alimental c have just enumerated. In France, where lead-colic is so common, low does it happen that gout is so rare among the great mass of the population ? Well, in cases of saturnismus there are a few patients with the gout in whom lead-poisoning is the only cause that can possibly be adduced. "We have ourselves had an opportunity to observe a very remarkable ease of this kind, and Dr. Bucquoy has just reported an almost identical case in Charity Hospital. It now remains to determine the cause of this singular coincidence. Garrod affirms that an impregnation of the system with had leads to an accumulation of uric acid in the blood, especially in advanced eases where there is paralysis ; this fact has been established in non-gouty cas saturnismus, which seem not to have been albuminurious ; for their urine had been examined, and it had been determined that the proportion of uric acid was sensibly diminished ; but in these analyses there was no qui of the presence of albumen. Garrod asks himself whether, in tin- there was an over-production of uric acid, or a failure in excretion of this product. He leans toward the latter hypothesis, and this is * ment on which he bases his view : after baring for several days examined the urine of a certain number of patients suffering from various disc - order to establish the normal proportion of uric aeid. he commenced to employ acetate of lead medicinally with them, and he found that the ex- cretion of uric acid diminished. It is then by paralyzing the action of the kidney, at least so far as con- cerns the elimination of uric acid, that lead favors gouty mar. but can the disease arise from the influence of this cause* alone ? In a few 1 G-. Musgrave: De arthritide symptomatica, c. x . art. 5, v C. H. Parry: Vol. i., p. 243. Loudon, 182o. Todd: Practical Remark^ p. 44 London, 1843. 2 W. Falconer: Brit. Med. Jour., p. 464. 1801. P,egbie : Edinburgh Med. Jour., p. 128. August, 1802. Charcot: Gazette Hebdom., p. 433. It THE DISEASES OF OLD AGE. 91 exceptional cases perhaps it can ; but if there are any adjuvant causes, the effects of lead will be exhibited last of all. LTI. — Exciting causes. — Incapable themselves of producing gout, still the conditions we are about to enumerate possess great potency in bring- ing about the development of an attack. A. — Alcoholic beverages. — The ingestion of but a small quantity of cer- tain wines (champagne and port, for example), in the case of gouty patients, is enough to induce at one time a violent attack of gout, and at another simply a swelling of the great toe. Hence, Garrod has well said : "In what- ever individual a few glasses of wine are always sufficient to rapidly and invariably provoke an inflammation in a joint, that inflammation is certainly of a gouty character." B. — Attacks of indigestion, and gastric derangements act in a similar manner. C. — Wet cold and suppression of the perspiration are in the same cat- egory. D. — Excessive intellectual labor, to which we have already alluded as a determining cause of gout, is included also in this enumeration. E. — Traumatic causes, operations, fractures, etc., act in like manner, and I have seen a wound simultaneously induce an attack of trismus and one of gout. F. — Debilitating causes — hemorrhage, bloodletting, and grave diseases — also exercise their influence upon the production of an attack. It is all the more interesting to notice this point, since people are fond of painting gout as a disease of plethoric individuals ; but Todd has shown that it readily attacks debilitated subjects. 1 "We shall devote our next lecture to the theory of gout. 1 Recently I had under my charge a former officer in the Confederate Army, who, during the rebellion in the United States, was made prisoner by the Union troops. Confined in a damp and unhealthy prison, and having a very insufficient diet, he be- came a subject of gout ; he remains so till this day. and yet he has no hereditary ante- cedents that could predispose him to gout, and previous to that time he never had the least indication of the disease. 92 CLINICAL LECTURES ON APPENDIX TO LECTCHE IX. English Beers. The question of the influence exercised by ale and porter upon the de- velopment of gout is one that frequently recurs in these lectures, and it seems to me to be necessary to present, in this connection, some descrip- tion of the processes employed in making these beverages, and the chief properties that characterize them ; so I requested Dr. Ball to prepare for me a short account bearing on these points, which I here present to the reader. The information therein is all the more useful, since it can be found in no medical work published up to this time. It is beyond dispute that, from the remotest antiquity, people who were not acquainted with the use of wine discovered the means of utilizing germinated barley (malt) in order to procure alcoholic bev- before they left their forests the Germanic tribes possessed this art. and thus we are not astonished to find beer naturalized in England from the time of the Anglo-Saxon conquest. The laws of Ina. King at \ country of the Western Saxons), which were promulgated in 72s, already make mention of ale and alehouses ; and from that epoch beer has never ceased to be the natural beverage of the English. But during the course of these many centimes public taste has varied more than once, and the brewers have been obliged to follow the fashion, except, indeed, when they have forestalled it. In the middle ages hops were not employed in beer-making, the beverage seeming to have fa insipid and sweetish taste ; and they endeavored to correct this fault by the addition of infusions of bitter and aromatic herbs. It was in 1524 that the Flemings caused hops to be introduced into English brewing ; but this practice was not legally authorized until 1552. The name ale was then given to the sweeter beverages prepared from malt {germinated grm n), while the term beer was reserved for those impregnated with the bitten- hops. In the seventeenth century, however, every vestige of this dis tion was swept away, and hops were universally employed in the English breweries. The origin of porter is of much more recent date. It was in 1730. ac- cording to Malone, that it commenced to be used for the first time. About Herodotus and Diodorus (of Sicily) tell us that the Egyptians knew how to make beer. Phny and Tacitus testify the same as regards the German*. "Potui humor ex hordeo aut f rumento in quamdam similitudineiu vini eorruptus." — Ta, moribus, ac populis Germ., cap. xxiii. THE DISEASES OF OLD AGE. 93 that time the workingmen of London were in the habit of drinking, in the ale- houses, a mixture of beer, ale, and small beer, which they called three threads, because for every pint he drew for a customer, the inn-keeper was obliged to go to three different casks. In order to avoid this inconvenience, the brewer Harwood thought he would make a beverage that would combine the flavor of these three ; he succeeded admirably, and the success attained by the new drink among the lower classes of the metropolis was such that the name porter ' was given it, a name which it has retained till this day. To please the popular taste, they formerly gave this porter a very deep color, by prolonged torrefection of the grain. But it was soon perceived that, by doing this, they destroyed the greater portion of the saccharine matter contained in the malt, and that the richness of the liquor in regard to fermentable principles was diminished thereby. Recourse was then had to a number of artificial processes for coloring porter, which were prohib- ited in 1816 by an act of parliament ; and the only ingredients which, to- day, serve for the manufacture of beer, are water, malt, and hops. It w T as then discovered, however, that complete torrefaction of malt, though destroying the sugar it contained, gave rise to a very soluble color- ing matter : and since then this substance, which came within the terms of the law of 1816, was largely enrployed in making porter. To-day this beverage is a mixture of several kinds of beer, kept a long time after being commingled, so as to push fermentation to its utmost lim- its and convert all the sugar into alcohol. But, since the malt is exceed- ingly torrefied at the commencement, it contains but little glucose at the very moment when the working begins, and consequently can never be as rich in alcohol as the other varieties of beer. Its essential characteristic, however, is a tendency to acetic fermentation, for, all the sugar being de- stroyed, one more step sufiices to convert the alcohol into vinegar. From a theoretical standpoint, this change ought never to take place ; but prac- tically the porter delivered for use is frequently acid, a fact of which I have many a time assured myself. The name entire is generally given to beers that have been mingled ; while stout is applied to one that is prepared with more care and is des- tined for more delicate consumers, though it participates in the general characteristics that we have just described. Under the name ale are classed all the other varieties of beer that do not possess a deep color, and are not prepared from excessively roasted malt ; hence, they are richer in saccharine matter and alcohol ; and as fer- mentation has not progressed far enough to destroy all the sugar they con- tain, they possess a very different flavor froni that of porter, and present no tendency to sour. Thus, we may divide into two great classes the beer that is used in the United Kingdom : the first class is rich in color, but poor in alcohol, de- prived of sugar, and ready to undergo acetic fermentation ; they are also impregnated with a principle obtained by the torrefaction of grain, and which perhaps is not alien to their pathogenic properties. To this class belong the beverages known under the generic name of porter, and whose use so markedly predisposes to gout. The second class, on the contrary, though poor in color, are rich in al- cohol, and do not contain a trace of acetic acid. It is understood, of course, that in this brief account we could not include 1 " Probably because the London porters first used it." — Webster. 94 CLINICAL LECTURES ON all the variation to which caprice, chance, or local customs may have given rise. In England, the beer of one county or shire does not resemble that of its neighbor ; and each distinguished brewer has his secrets, which especially stamp the products of his manufacture. It is enough, then, to have presented the reader with a general view of the subject, without en- tering into a minute study of details. THE DISEASES OF OLD AGE. 95 LECTURE X. PATHOLOGY OF GOUT. Summary. — Rational Theory of Gout — It can hardly be Formulated in the Present State of Scientific Knowledge — Cullen — Discovery of Lithic Acid (Uric Acid) — Influence of this Fact upon Modern Works— Garrod's Researches — He establishes the Fact that Uric Acid exists in Excess in the Blood of Gouty Patients — Origin of this Excrementitious Product — It is still but little known — Are Urea and Uric Acid Immediate Products of Disassimilatiou ? — Experiments of Zalesky. Empirical Researches— Effects of Fasting — Animal Diet — Exercise — Contradic- tory Results in this Respect — Influence of Liquors : Experiments of Booker. Theory of a Gouty Attack (Fit)— The Articulations preferably affected — Fibrous Tissue, Cartilage — Predilection of Gout for the Great Toe — Successive Invasion of Joints — Tophi — Deposits of Urate of Soda in the Cartilages — Pain — General Re- action — Visceral Phenomena — Insufficiency of our Knowledge in this Respect at the Present Day. Gentlemen : — After havirig passed in review the various causes which are closely or remotely associated with the production of gout, there re- mains for us to seek a rational theory of this disease, and to combine the data of physiology with those furnished us by clinical observation. We may not, besides, flatter ourselves that we can obtain complete success in this direction ; for, even though we know the morbid principle whence arises, in this case, the pathological series of events, we are yet far from grasping all the links in the chain ; the conditions presiding over the for- mation and elimination of uric acid are still unknown to us, and will, no doubt, long elude our investigations. In order to understand, however, the present state of the question, it is necessary to trace the various phases it has passed through during the course of years until the present day. Let us see, then, what the opinion of our predecessors was in this respect. The theories which were formulated concerning gout during all the seventeenth and part of the eighteenth century were essentially associated with humorism ; this is always the theory of Sydenham, in slightly differ- ent words. There is morbific material in the body, the result of imper- fect digestion occurring either in the primce vice or in the secondary appa- ratus, and the efforts of nature to eliminate this peccant material (phlegm, bile, tartar) constitute the symptoms of gout. But a reaction against these old ideas set in from Cullen's time. This celebrated author held that there was no proof of the existence of a morbific material in the blood. He regards tophi, adduced by the humorists in support of their theory, as purely accidental occurrences. For him, gout results from a sort of plethora, with loss of tone in the extremities. The progress of chemistry stepped in to modify, to a certain extent, this method of regarding the disease. In 1775, Scheele discovered lithic acid (uric acid) in urinary calculi and in the urine ; in 1793, Murray Forbes, 96 CLINICAL LECTURES ON by reason of the analogies subsisting between gout and gravel, promulgated the view that uric acid existed in the blood of the gouty ; in 1797, Tennant and Wollaston established the composition of tophi to be of urate of soda. Cullen's theory, however, still held sway in England. Scudamore con- tinued to regard gout as a sort of plethora without any relation to the ex- cess of uric acid in the blood ; he considers tophi as exceptional phenomena in gout, having found them in but forty-five out of five hundred gouty subjects. Barlow and Gairdner share this opinion ; and recently Barclay l has again recurred to this point, relying, it must be said, much more on sentiment than upon observation. But Parkinson, Home, and Holland are identified with the uric acid theory. In France, gout has been studied only by a limited number of writers ; but those who have devoted themselves to this subject admit, at least theo- retically, the presence of uric acid in the blood, and fully understand the importance of this cardinal fact. In this connection we may especially cite Andral, Bayer, and Cruveilhier; 2 the latter regards the deposit of tophaceous matter in the interior of the articulations and in their vicinity as the char- acteristic lesion of gout. Now, these tophi consist of urate of soda ; and Cruveilhier is thus led, he says, in spite of himself, to the theory of Syden- ham and the older investigators : he regards urate of soda as the material cause of gout, and he considers that there is no doubt but that the first attack of gout coincides with a secretion of this product, which is afresh with each subsequent attack of the malady. Notwithstanding all the interest offered by the works we have just men- tioned, the period of positive knowledj date from Garrod'i investigations in 1848. This observer, so often quoted in the course of these lectures, has established : fint, that in acute or chronic gout th- an excess of uric acid in the blood: secondly, that from the first attack there is a deposition of urate of soda in the joints ; thirdly, that during the attack or paroxysm there is an appreciable diminution in the excreta uric acid by the kidneys. These are the fundamental facts that may serve as elementary princi- ples of a pathogenic doctrine ; but there is still no physiologic*] du- gout in it. A few attempts, however, have been made in that direction, and I shall present you with the chief results thereof. I. — The presence of an excess of uric acid in the blood does not consti- tute gout, 3 but merely induces a marked predisposition to this malady. "We must, then, study the various circumstances that may augment proportion of this excrementitious product ; but we are met with difficul- ties at the very first step. What is the origin, what are the sources of the uric acid exert: Authorities do not agree concerning this point. A. — The theory of direct combustion, advanced by Liebig, seems to af- ford a ready solution to the problem. Uric acid has its origin in the I itself, at the expense of the albuminoid matters (fibrin, albumen, globulin) which have not been oxidized sufficiently to convert them into 1 On Gout and Rheumatism, p. 3 and following. London. 181 2 Andral: Precis d'Anatomie Patbclodque. Vol. i.. p Vol. ii.. | 1829. Rayer: Trait:- des Maladies des Reins. Vol. L, p. 843. Pw veilhier : Atlas d'Anat. Pathologique. Tart 4. Plate iii. s Albuminous nephritis and the saturnine cachexia are also among the number of diseases accompanied by an excess of uric acid in the \ THE DISEASES OF OLD AGE. 97 Here is an excess of receipts over expenses ; an individual has eaten too much, taken too little exercise, and hence, gout is developed. But it has been recently proved that it is always the urea which in- creases, and not uric acid ; and besides, according to the researches of Bischoff and Voigt, these two products are the result of the disassimila- tion of the elements composing the tissues, and are never directly formed in the blood. B. What, then, are these organs, what are these tissues from which uric acid is formed ? Again we find ourselves in the face of contradictory re- sults. Urea comes from the muscles, we are told, and uric acid from the pa- renchymatous viscera ; and, indeed, it has been found in brain and liver, in the spleen (Scherer), and in the lungs (Cloetta). A few pathological facts tend to confirm this idea : thus, Uhle and Banke found an actual ex- cess of this acid in the urine in a case of splenic leukaemia ; and Harvey obtained the same result in diseases of the liver. Other physiologists say that urates arise from cartilage and fibrous tissue, and organic movement is certainly less active in them because of their scanty vascular structure, as Bartels ' has remarked ; consequently, oxidation takes place in an incomplete manner. The investigations of Professor Robin 2 have led to an analogous result. He admits that in fibrous tissue the albuminoid materials are changed into glutin ; and this substance, in its turn, breaks up into uric acid and urates by a process of disassimilation. Hence, it is evident, that when the work of disassimila- tion is exaggerated in these parts, the result will be a satiu*ation of the blood with these products — in other words, a uric acid diathesis. Professor Robin has also found uric acid in normal fibrous tissue ; 3 and hence, the pathological condition is to him nothing but an exaggera- tion of what occurs in a state of health. He explains, in this way, why the articulations are the principal seat of the lesions in gout : their richness in fibrous tissue renders them unusually liable to be attacked in the disease. Without denying the plausibility of this explanation, let us remark that the theory according to which uric acid and urea are the immediate products of disassimilation is certainly deserving of respect, although after all it is merely an hypothesis. Its foundation rests especially °on the presence of these two substances in normal blood ; but they are found only in the minutest proportion in mammals, while in birds and reptiles they seem wholly wanting. 4 The presence of urea and uric acid in the tissues has also been advanced in support of these ideas ; but as for urea, this is not the fact, except in morbid states ; in the normal condition of affairs kreatin and kreatinin alone are found in the muscles. Concerning uric acid, the case 4s better proven. In any event, the investigations of some of the modern scientists seem to invalidate this hypothesis. According to Zalesky, urea and uric acid are formed in the kidney at the expense of kreatin : tie the ureters in a dog, and you will have an accumulation of urea in the blood ; extirpate the kidneys, and there will be no such phenomenon. In reptiles there will be an accumulation, not of urea, but of uric acid, when the ureters are ligated ; 1 Deutsche Archiv fur klin. Med., Bd. i., Heft 1, p. 13. Leipzig 1865 2 Dictionnaire de Med. (de Nysten), p. 678. 1865. Programme du Cours d' Histolo- gic, p. 90. 1864. 3 A verbal communication from Professor Robin. 4 Zalesky : Untersuch. iiber den uramisch. Process. Tubingen, 1865. Recent re- searches of G-rehaut appear to invalidate the results obtained by Zalesky 98 CLINICAL LECTURES ON but ablation of the kidneys is followed by no such occurrence. Zalesky concludes therefrom that urea (in those animals that secrete it) and uric acid are formed within the kidney itself, and have not previously existed in the blood. In this direction, then, we do not find any really important data, any really solid foundation upon which we can establish a rational doctrine, and hence we must have recourse to other means of investigation. II. — The purely experimental research into the conditions which induce a variation in the proportion of uric acid in the renal excretion at least furnishes us with some interesting information. The proportion of uric acid increases after a meal (Bence-Jones) ; fast- ing diminishes it by one-half, and a vegetable diet acts in a similar manner. All authors since Lehmann agree as to the effects of a purely animal regimen ; there is an increase of uric acid and urea, but especially of the latter product. Theoretical deductions seem to accord quite closely, up to this point, with the data furnished us by observation from the standpoint of gouts etiology. But in proceeding with this study we shall very soon encounter contradictions. It is, for instance, a generally admitted fact that exercise is one of the best means for preventing the uric acid diathesis. Lehmann's experiments confirm this view ; he has established beyond all dispute that muscular activity results in an augmentation of the quantity of urea and a diminu- tion in the proportion of uric acid. These results have been confirmed in the case of urea, but contradicted concerning uric acid. Beneke, Genth, and Heller ' found that prolonged exercise during three hours had the effect of increasing the quantity of this product Ranke,* and Speck admit that unusual activity may be followed by the same results. And, in the main, however violent or prolonged the work may be, there is rati., increase than a diminution of uric acid. Concerning the activity of the respiratory functions, it is generally admitted that the more this increases, the greater is the diminution in uric acid, while the proportion of urea is augmented. Still, it must be acknowl- edged that this view rests upon no very well established facts.' In spite of the interesting experiments of Bocker, 4 we cannot as conclude anything concerning the influence of alcohol. According to this investigator, alcohol and spirituous liquors diminish the production of urea and urea acid ; wine, on the other hand, tending to increase it, as the pre- vious experiments of Liebig had already proved. When beer does n as a diuretic, it diminishes the quantity of urea and increases that of uric acid, but only very slightly. Finally, tea and coffee diminish the propor- tion of this substance. If, in these experiments, it be admitted that the quantity of uric acid passed in the urine corresponds to that formed in the economy — which is quite probable, since the subjects who have aided in attaining these results were in full health — it can be proved that al and spirituous beverages act here wholly different from beer and wine, agreeing thus with the data of clinical observation. 1 Beneke : Nord See Bad., p. 35, 1835. Genth : Untersuch. iiber den Einfluss der Wassertrinkens auf dem Stoffwechsel. Wiesbaden, 1S56. Heller: Heller's Archiv Neue Folge. - Ranke : Anssch. der Harnsaure. Miinchen, p. 240. 1 E 3 Consult Parkes : On the Urine, pp. 50 and o20. 4 Bocker: Beitrage zur Heilkunde. Vol. i., p. 240. THE DISEASES OF OLD AGE. 99 Upon the whole, contemporaneous chemical and physiological sciences have not yet shed a very brilliant light upon the all-important question in gout, namely, the presence of uric acid in the blood. Since, however, the reality of the latter phenomenon has been experi- mentally proved, can we, accepting this as a starting-point, deduce from it the other symptoms of this disease ? This has been the aim of Garrod's endeavors ; and we shall exhibit the results of his labor, asking you to no- tice, however, that it is now no longer a deduction of a general theory of gout, but only the question of an attack. m. — We have already seen that various circumstances are preparatory to the occurrence of a gouty attack and render it imminent. Some have the effect of accumulating uric acid in the blood, either by directly favoring the production of it (excessive meals and abuse of certain beverages), or by di- minishing the excretion of this product (lead-poisoning, painful emotions). Others, again, attack the solubility of uric acid in the blood by diminish- ing the latter's alkalinity ; such are the impression made by cold, checking the acid secretion of the sweat, and the use of acids, vinegar, etc. We may suppose, then, that the presence of an excess of uric acid abruptly thrown into the circulatory stream explains the nervous derange- ments, the dyspeptic and other premonitory symptoms which immediately precede an attack of gout. Up to a certain point the local symptoms may also be referred to a simi- lar explanation. We shall now review the most important of these phe- nomena, assuming, for that purpose, a standpoint such as we have just described. Gout preferably affects the articulations. Here is a point of similarity with other dyscrasise which have a predilection for the joints. We see this in purulent infection, in glanders, and in the therapeutical exhibition of ar- senic ; and lactic acid introduced into the veins seems also to expend its action upon the joints (Kichardson). Gout preferably affects fibrous tissue, and especially cartilage. This unpleasant prerogative may be attributed to their scanty vascular structure and to the relatively slightly alkaline reaction of their own tissue — two cir- cumstances which clearly favor the formation of those crystalline deposits characteristic of the disease. Gout preferably invades the metatarsophalangeal articulation of the great toe. This perhaps arises from the fact that the joint is one of the farthest from the circulatory centre ; and it also undoubtedly occurs be- cause this articulation is often called upon to support the entire weight of the body, frequently presenting lesions before any gouty manifestations ap- pear. It is well known, besides, that traumatic causes have the effect of inducing the invasion of gout. We can explain, to a certain extent, the successive implication of the articulations, for when extensive deposits have formed upon the cartilages of a joint, it may be said that this point is saturated ; whereupon the other articulations take it up, following a more or less regular order. Tophi also acknowledge as their cause a saturation of the cartilages ; and thus their formation is always a subsequent phenomenon. It may be asked whether the deposits of urate of soda in the cartilages are the cause or the effect of the local inflammation. Garrod inclines toward the former view. He says that the inflammation excited by these deposits seems to have the effect of destroying the urate of soda, and that, following an attack, the blood contains considerably less of this salt. J3e- 100 CLINICAL LECTURES ON sides, the deposits which form externally are not preceded by inflammatory action, and, even if they sometimes give rise to symptoms of this nature, it is solely because they are foreign bodies (external ear). And thus the formation of these deposits in the cartilages precedes the first attack, while the formation of new deposits, either in the same joint or in new articulations, brings about those local phenomena that character- ize subsequent attacks. But why this excruciating pain inaugurating the series of articular symptoms ? It cannot be attributed to inflammation ; local fluxion is pre- cisely as intense, but certainly far less painful in articular rheumatism. According to Garrod, we must attribute it to the presence of the deposits themselves deep in the cartilages, and to the tension which they induce thereby ; for only when gout is intra-articular is the suffering so great ; when the deposits are external, it is not equally severe. Finally, symptoms of arthritis appear, and a general reaction is caused by the local phenomena, it being well known that its intensity is usually in proportion to the number of articulations attacked and the degree of local inflammation. Such, gentlemen, is the state of our knowledge upon this subject. I have considered it proper to devote myself to a discussion frequently ren, in order to show you how much progress, in this remains for us to make. Concerning visceral gout, we have previously described the resul* Zalesky's interesting experiments ; these have shown us that the ligation of the ureters induces, in many animals, the formation of deposits of ni soda in the stomach-follicles. It is highly probable that in man the <: intestinal juices are loaded with urates, in cast- of saturation. Undoubt- edly, analagous phenomena might also be produced bearing on I points. In those animals upon which he experimented. Zalesky found a large proportion of urate of soda in the muscle-extract We all n understand the importance of these facts from the standpoint of gout's visceral symptoms, but what is less easily explained are the sudden I stases which cany the morbid action from one point to another — from the great toe to the stomach, and from the stomach to the joints. Concerning this point, science has certainly not pronounced her last dictum. It yet remains for me to speak of the therapeutical measures which we can employ against gout, but I prefer to leave this until we take up the treatment of chronic rheumatism ; for, by thus twinging them together, we shall find the elements of a comparison as curious as it is instruct] THE DISEASES OF OLD AGE. 101 LECTUKE XL CHRONIC ARTICULAR RHEUMATISM AND ITS ANATOMICAL LESIONS. Summary. — Chronic Articular Rheumatism Essentially a Hospital Disease — Nature of the Malady — Relation to Acute Rheumatism — Principal Varieties of this Affection — Chronic Progressive Articular Rheumatism (Gouty Rheumatism) — Chronic Par- tial Articular Rheumatism — Heberden's Nodes ; not to be confounded with Gout. Anatomical Characteristics of Chronic Articular Rheumatism — Necessity of a Careful Study of the Local Lesions — Unity of the Disease — Earliest Works Rela- tive to this Subject. Fundamental Characteristics of Chronic Rheumatismal Arthritis — Changes in the Synovial Membrane ; in the Articular Cartilages; in the Intra-articular Fluid ; in Osseous Tissue— Histological Study of these Different Lesions— Modifications cor- responding to the Chief Clinical Forms of the Disease. Gentlemen : — After having thoroughly studied the history of gout, we are now about to take up a disease so closely allied with it, that very fre- quently the two conditions have been confounded ; but we hope to be able to prove to you that this similitude is without foundation, and that chronic articular rheumatism has a place reserved for itself apart from gout. With regard to chronic articular rheumatism, the succeeding subject of these lectures, we enjoy a great advantage ; for, while gout is not one of the diseases commonly met with in the hospitals of France, and is, besides, an affection quite infrequent in the female sex — while gout is almost un- known in the Salpetriere, chronic rheumatism is, % on the contrary, one of the commonest infirmities in this institution ; and indeed, this disease prevails among women and among the least-favored classes of society. In this way the proportion of patients admitted to the hospital for this kind of lesion is about one-fifteenth of the total number of inmates. Most of those authors who have made a special study of this disease have drawn on institutions analogous to the Salpetriere for their observa- tions. In England the ivorkhouses furnished the interesting materials for Colles, Smith, and Adams' publications. It was, you know, in the Salpetri- ere that Landre-Beauvais wrote the monograph which we have already had occasion to quote. We are about to undertake, then, a truly clinical study, and I shall frequently have the opportunity to present you, not only with anatomical specimens, as has so often been done up to this time, but even with patients who are suffering the lesions I shall describe to you. I. — The name I have chosen to designate the disease in question sanc- tions a nosological interpretation which I unreservedly maintain, but which all authors do no admit. Among the adversaries of the opinion which I hold, some declare that we have here to do with a special disease, one completely independent of gout and acute articular rheumatism : this is Garrod's rheumatoid arthritis and the rheumatic gout of Fuller. Others again, consider the various forms of nodular rheumatism as subordinate to gout. 102 CLINICAL LECTUPwES ON I shall endeavor, gentlemen, to justify the ideas which I uphold, and to- show you that chronic articular rheumatism is sometimes seen, at the bed- side, proceeding directly from the acute form, precisely as chronic lobar pneumonia may follow acute pneumonia. The fact is, however, that the chronic form of articular rheumatism almost always develops spontaneously, and without passing through the acute fonn ; but this negative fact can- not invalidate the connection we are endeavoring to establish. As for gout, we shall institute, later on, a radical distinction between the two affections. II. — Chronic articular rheumatism appears in various aspects, and of such dissimilar appearance that many authors have concluded that several different diseases are presented them. We, however, only see in them the various forms of one and the same affection. To give but a single illustration, it is enough to state that many writers are ready to admit that nodular rheumatism is nothing but a poly-articular rheumatism in the chronic stage ; but they refuse to recognize a rheuma- tismal origin for the disease when it is localized in a single joint, and there slowly and insidiously produces the grave and deep-seated lesions of m coxce senilis. We hope to be able to prove to you that it is quite impossible to make an actual distinction between the various forms of rheumatism, but that, on the contrary, it is frequently possible to show that they all proceed from one and the same source. It is, however, indispensable, from a clinical standpoint, to make a separate study of the principal varieties of chronic rheumatism, just it were really a question of several distinct diseases ; this is the only way to avoid confusion. And this preliminary work finished, we shall endeavor to demonstrate the common tie binding them together. There are numerous types of chronic articular rheumatism ; but we shall devote our attention chiefly to the following : 1. Clxronic Progressive Articular Rheumatism. This is the gouty or nodular rheumatism of certain authors : the/>rn asthenic gout of Landre-Beauvais, and Haygarth's nodosities of joints. This is the gravest form of the disease, being accompanied by deplorable in- firmities. Although exhibiting a preference for the smaller joints. i: also invade the large ones ; and it frequently induces muscular retractions and other symptoms. Two kinds may be distinguished : tins disease, sometinies/>n?>ion/, some- times secondary to the acute (the latter rare, however), may be either be- nign or malignant. It is not always concentrated in the joints, but may be accompanied by visceral diseases, at times analogous to those of acute rheumatism sionally proceeding therefrom), and at others again by those peculiar to chronic rheumatism ; in the latter category we must place ophthalmia and albuminous nephritis. The local changes are those of a dry aiihritis. which are, besides, except- ing a few secondary modifications, common to all the forms of chronic rheu- matism. THE DISEASES OF OLD AGE. 103 2. Partial Chronic Articular Rheumatism. The joints affected in this variety are few in number, sometimes only- one. The articular changes are the same as in the preceding variety, but are much graver, as seen in the case of morbus coxce senilis. Foreign bodies, which sometimes develop within the' joint, are frequently, in such cases, of an exceptional size. Visceral implication or abarticular affections are, on the contrary, quite infrequent here, although they sometimes do exist. It is in the benign form of the disease that we are especially liable to meet with them — certain forms of asthma, and skin diseases, occurring in some of its subjects. In the malignant form, where visceral affections are rare, and where the whole disease seems to be concentrated upon the affected joint, the case is wholly different, although albuminuria has been seen in a few exceptional cases. 3. Heberden's Rheumatism. Heberden's nodosities (digitorum nodi) constitute the mildest type of this disease. It is at this point especially that it becomes necessary to enter into a critical discussion. When it is a question of nodular rheumatism, the dif- ference from gout, at least in certain characteristics, is generally conceded ; but it is not the same with the variety we are describing. It may be said that no one doubts but that these lesions are certainly and consistently re- lated to gout. We are constrained to hold a diametrically opposite opin- ion ; and we purpose to describe in a very painstaking manner the arthritis which preferably attacks the second articulation of the fingers, deforming them in such a strange fashion. These lesions have certainly engaged the attention of many an investi- gator, but they have not yet been studied with all the care they deserve. Pathological anatomy will very soon enable us to recognize that, excepting their special seat, these arthropathies differ in no way from those which constitute the two preceding types ; and we shall eventually have the op- portunity to justify, from a clinical point of view, the separation of this particular type from them. It is enough, at present, to observe that in ordinary cases we meet here only with nodosities of the terminal phalanges, almost always indolent and without any complication. Sometimes, however, there are several other joints, some of which are among the most important articulations, that are simultaneously affected ; and indeed, the articular lesion may be accom- panied by muscular or neuralgic pains ; sometimes in the sciatic, the tri- facial, or in other nerve-trunks. Among the visceral diseases which may occur in this variety, we may especially indicate asthma and megrim. HI. — We are now about to consider the anatomical characteristics of chronic rheumatism. When we attempted to sketch the history of gout, we met at the very commencement a fundamental fact which governed all the symptomatic manifestations of the disease — we mean the change in the blood from an ex- cess of uric acid. We find no characteristic with such a general bearing to guide us in the study of chronic rheumatism ; and although it is probable 104 CLINICAL LECTURES ON that a special modification in the fluids of the economy exists in rheuma- tism as well as in gout, the hypothesis is still far from having been demon- strated. A thorough and careful examination of the local lesions is, therefore, what we -must here have recourse to ; and we shall pursue our researches from the dual standpoint of the clinic and pathological anatomy, though laying especial stress, for the 1 time-being at least, upon the latter aspect of the question. In the first place, pathological anatomy enables us to establish the unity of this disease ; for the various forms it may assume are distinguished by clinical characteristics principally, presenting, with respect to local changes, a common type modified by a few differences of lesser import. In the sec- ond place, it enables us to unite the chronic with the acute or subacute form of articular rheumatism; and finally, to demonstrate a radical differ- ence between this affection and those other diatheses, which, along with it, enjoy the privilege of localizing around the joints ; such, for example, are gout, scrofula, and syphilis. We are not compelled to go very far back in history to meet with the first works bearing upon our subject. The physicians of antiquity, as we have already remarked, seem to have confounded articular rheumatism with gout, and we may ask ourselves whether the first of these two diseases is not one of those peculiar to mod- ern times. Archaeology comes to the aid of medicine on this question, and Pompeiian excavations tell us that chronic rheumatism was already in ex- istence during the first century of the Christian era. Delle Chiaje, in a work entitled "Osteologia Pompeiana," has depicted articular Lesions iden- tical with those which are found in the plates of Adams' HlMwiffll work. Concerning this point, then, there can be no doubt whatever ; but eluonic rheumatism was not recognized as a separate morbid species until the time of Sydenham and Musgrave, and the first monographs devoted to the study cf this question date from the commencement of this century. Wi quote in particular that of Landre-Beauvais (an "NTH.), Haygarth (1809), and Chomel (1813). A little later on the fundamental features of chronic rhcu- matismal arthritis were published ; in France, Lobstein ( 1 aking with reference to arthritic osteojjsathi/rose ' noticed that the bones in this disease were especially fragile, that destruction of the articular car- was followed by eburnification, and that osseous vegetations formed around their articular extremities. About the same time an Irish physician. Colles, remarked that this inflammation differed from others by a very es- pecial characteristic ; he says: "Two very different pi aking place at the same time, namely : absorption of the old bone audits articular cartilage, and the formation of new osseous tissue. " But to Adams, 2 a contemporary and countryman of Colles. we are 1 1 cially indebted for the best studies that have 'been made of this subject (1839-57). So far as examinations by means of the naked eye are con- cerned, his descriptions leave but little to be desired ; but a special men- tion is due the works of Deville and Broca upon dry arthritis (1850). In certain respects they completed the descriptions given by Adams. In our days histological investigations have shed a penetrating light upon this question. 1 Osteo-psat7iy?-ose : a condition of bone accompanied by extreme fragility, and probably the fragilitas osseum of English, and the 06 in and some French authors.— L. H. H. 8 A Treatise on Rheumatic Gout. By R. Adams. K. D. . etc. London, 1 v THE DISEASES OF OLD AGE. 105 In Germany, Zeis, H. Meyer x and Otto Weber, 2 tell us how each tissue is changed under the influence of chronic rheumatism, and have in this way suggested reasons for many phenomena that otherwise would have remained unexplained. In France, Ranvier, Cornil, and Vergely, 3 have confirmed and cleveloped the results of these investigations. It is by means of these documents, and the studies we ourselves have made, that we shall describe to you the morbid action that characterizes chronic articular rheumatism. A. SUMMAKY OF THE FUNDAMENTAL CHARACTERISTICS OF ChEONIC RhEUMATISMAL Arthritis. The disease we are about to study involves all the structures that con- stitute the joint, but it is first exhibited upon the synovial membrane and the articular cartilages; these two parts may be affected simultaneously or in succession. The synovial membrane becomes extremely vascularized ; the pre-existent synovial fringes increase in size and there is a formation of new villous appendages; and finally, foreign bodies may develop, either at the expense of the fringe-like processes themselves, or deep within the syno- vial membrane. There is, at the same time, a change in the synovia of the articulation: at first there is an increase in the secretion of the fluid, and this, according to Adams, is a constant occurrence. Later, the intra-articular fluid may undergo various changes, but it never contains pus, except when certain complications exist. Destruction of the articular cartilage occurs in a manner already known to William Hunter, and thoroughly studied by Red- fern; 4 it passes under the name of the " velvety " change. 5 The cartilages are first seen to break up into a fibrillar structure, then these fibrils them- selves disappear, and the cartilage is destroyed. Now, let us see what are the changes occurring at the same time in the osseous tissue. There is, first, eburnation of the articular surface, either at the expense of the deeper portions of the cartilage or of the pre- existing bone ; osseous vegetations simultaneously occur, located, most commonly, at the extremities of the cartilage. These osteophytes have, at first, a cartilaginous structure, but soon are impregnated with calcareous salts, finally ossifying. A third change, whose importance at least equals that of the preceding lesions, is the rarefaction, the decrease in density, of the osseous tissue at the articular extremities. At first there is marked vascularization beneath the layer of ivory-like substance, and a bony marrow of new formation de- velops at this point ; secondly, the bone becomes very much less dense, and is transformed into a kind of fatty marrow underneath this spot. These are the fundamental facts which it is important to state here. There are, no doubt, many other alterations ; but, since they are not com- mon to all the forms of articular rheumatism, we shall reserve their study for a more suitable occasion. 1 Miiller's Archiv. 1849. 2 Vir chow's Archiv, p. 74. January, 1858. 3 Ranvier: Theses de Paris. 1865. Cornil (translation of Niemeyer : Pathol. In- terne. Vol. ii , p. 556. Vergely : Theses de Paris. 1856. 4 Edinburgh Monthly Journal. 1849. 5 The numerous fibril la? at right angles to the articular surface give to the latter a velvety appearance. — L. H. H. 106 CLINICAL LECTURES ON At present we shall take up each point just described, and study it in a more thorough manner, aided by all the means of investigation which to-day are at our command. B. — Histological Study. I t — Changes in the synovial membrane. — To a certain extent, these altera- tions merely consist in an exaggeration of the condition existing normally in a rudimentary state. It is well known that the synovial membrane has fringe-like processes which themselves present appendages. 1 In the pathological state these little prolongations are seen increased in number, and presenting a greater vascularity. Normally, there are cartilage-cells in these synovial appen K., Hi- ker). These cartilaginous nuclei may become the starting-points for those pediculated foreign bodies of which we have already spoken. According to Eanvier, there is, first, cell-proliferation ; then the formation of true car- tilage ; calcification next takes place ; and finally we have ossification prop- erly so-called, with bone-corpuscles. Within the deeper structure of the synovial membrane sesrife bodies may be developed, passing through precisely the same phases as those which are pediculated. 2. Changes in the cartilage. — "With regard to articular cartilage, we find ourselves confronted by two principal facts : the first \b proliferation of cells, and the formation of secondary capsules ; the secoi. tion of the fundamental tissue. It breaks up into fibrils which are free at that extremity cor- responding to the articular cavity. This pathological process ought to be stud- ied on tin of the cartilage, and in its deeper paj Upon the surface this segmentation has the effect of opening a passage for the capsules of the cells, and then the contents of these cap- sules escape into the articular cavity. They are frequently found along with a dibris of epithelial cells (Rindfleiseh, O. Weber), and at other times they undergo colloid inetainorph- Concerning the' fibrils of the cartilage's fun- damental substance, they undergo inuoous de- generation or softening, and are transformed intomucosiu (Rindfleisch), which in considerable quantities in the articular fluid. Again, those portions of the cartilage I altered are very gradually worn away by articular rubbing, finally drop- ping off and laying bare the bony surf a/- Within the deeper parts cell-proliferation results in the formation of a new bony layer ; the primitive capsules become infiltrated with calctt matter and open into the superficial medullary spaces ; the cells which 1 K611iker: Elements d' Histologic Humaine, trans, of lk-elard u Paris, 1856. Fig. 12. — Nodular rheumatism: surface of a cartilage from a phalan- geal articulation. (After Ilanvier). a, primary, filled with secondary capsules ; b, segmented fundamental substance. The primitive capsules have just emptied their contents upon the free surface of the cartilage. THE DISEASES OF OLD AGE. 107 contain become the embryonic cells of the marrow, and at their expense there is formation of new osseous tissue. In this way eburnation of the surface occurs ; it is a sort of sclerosis of the bone, accompanied by vascularization of the deep parts. Here we no- tice a strange phenomenon taking place, and one recalling, in a certain rough way, the facts observed by geologists relative to the action of glaciers upon rocks. The ivory- like surfaces present stripe — radiat- ing lines that are of greater or less depth in the direction of articular movements, and thus evidence an imperfect repair in the presence of the wear (" usur ") occasioned by the constant rubbing of the surfaces. The articular cartilage, as you know, is covered at its peripheral portion with synovial membrane. According to Ranvier, this condi- tion, in cases where the articulation is invaded by rheumatism, hinders the capsules opening into the artic- ular cavity and pouring then* con- tents into it. But they continue, then, to proliferate at the spot, thus determining the formation of those rounded swellings or pads which are noticed on the part, and which, at first cartilaginous, ulti- mately become osseous. Ranvier also ascribes all the new bony formations developed under such circumstances in cell-prolifer- ation of the articular cartilage. The periosteum, however, probably assumes a certain share in their production, while there may likewise be simultaneous ossification of the articular cap- sules, the ligaments, tendons, and muscles. As for the interarticular liga- ments — the meniscuses, etc. , they are worn down and made to disappear by a mechanism analagous to that which destroys the cartilages — a subject which, however, has not yet been sufficiently studied. These, gentlemen, are the most general facts that I find necessary to describe to you ; but there are numerous modifications in this respect, ac- cording to the clinical form of rheumatism under consideration, and to some particular circumstances resulting from the very conditions of the disease. It is in this way that the changes met with in an articulation en- forced to absolute repose differ from those accompanying more or less com- plete preservation of movement. We have proceeded until now, under the latter hypothesis, but at present we shall study the changes arising in cases where the joint is immovable. In such instances, according to Adams, eburnation is no longer ob- served, but there is a neoplasia of connective tissue at the expense of the synovial membrane. According to Forster, the cartilage may also partici- pate in this process ; sometimes the fundamental substance may undergo Fig. 13. — Nodular rheumatism : deep layer of a phalangeal cartilage. (After Ranvier.) a, normal capsule ; 6, capsules near bones, enlarged and filled with secondary capsules ; c, primitive capsules about to open into the medullary spaces and to empty their contents therein ; d, osseous substance ; e, marrow filling the areola? upon the surface. At this point it is embryonic, for the capsules have poured out their contents there ; a little farther on it is adipose. 108 CLINICAL LECTURES ON this change ; and again, on the other hand, it may be the cartilage-cells that assume the appearance of connective-tissue cells. "Whatever may be the value of this theory, we see the formation of embryo-plastic tissue uniting the bones together, and, at a certain period, becoming vascularized ; then an ankylosis is formed, which is sometimes fibrous, sometimes osseous. The latter occurrence is very rare, taking place only in the very small joints. The influence of prolonged rest has, moreover, the effect of leading to atrophy and extreme friability of bone-tissue ; and perhaps there is a dis- appearance of the round, pad-like swellings with the corresponding vege- tations. This atrophic process, common in general rheumatism, is, like- wise, sometimes seen, though rarely, in morbus coxcb senilis (Adams). C. — Modifications Corresponding to the Principal Forms of Chronic Ar- ticular Rheumatism. The description we have just given applies principally to general and to Heberden's rheumatism. Here we find the changes of a dry arthritis in a rudimentary condition ; but in partial arthritis they present an enormous development, and become almost unrecognizable. Immense osseous vege- tations are seen to form : as, for example, in Wear- ing erosion ("vxur") and eburnation of cartilage and bone are exhibited in the highest degree, and eventually result in a deformity of the head of the bones. And finally, it is here that atrophy of bone is manifest to the very greatest extent — lesions which used to be explained by osteomalakia and senile rachitis (Malgaigne, Hattier). In those articulations which, for reasons still but imperfectly known, admit of the presence of foreign bodies, an immeasurable quantity of these is seen developing ; as, for example, in the shoulder and knee ; but it is quite the contrary in the case of the hip-joint, or the joints of the fingers. There is, besides, considerable thickening of the fibrous capsules, and ossi- fication of ligaments and tendons. Let me remark, however, that these differences cannot justify a radical separation ; in partial rheumatism there is a large number of joints where changes have occurred only in a very slight degree, and in general rheumatism some of the diseased articula- tions present lesions quite as marked as in the partial variety : this, for ex- ample, occurs in the vertebral column. To complete this study we must needs institute a comparison, with ref- erence to their anatomical points, between chronic rheumatism and the other arthropathies of slow development. But, before broaching this sub- ject, we desire to point out the analogies which bind the chronic to the acute form of articular rheumatism. THE DISEASES OF OLD AGE. 109 LECTURE XII. COMPARISON BETWEEN CHRONIC ARTICULAR RHEUMATISM AND THE OTHER CONSTITUTIONAL ARTHROPATHIES, FROM AN ANATOMICAL STANDPOINT. Summary. — Analogy between the Lesions of Chronic Articular Rheumatism and those of Acute— Changes in the Joints in Acute and Subacute Articular Rheumatism — Sometimes Null and Insignificant, sometimes Manifest — Arthritis with Exudation — The Inflammation not Superficial — The Cartilages and Bone may participate in the Process — Lesions of the Synovial Membrane — Lesions of the Articular Carti- lages — Lesions of Bone — Nature of the Fluid poured out into the Synovial Cavity- Analogy between these Lesions and those of Chronic Rheumatism. Characteristics that Distinguish Arthritis Deformans from other Arthropathies — Arthritis from Prolonged Repose — Scrofulous Arthritis — Syphilitic Arthropathies — Gouty Diseases of Joints. The Changes in Chronic Rheumatism Lack a Specific Character — They may arise from Many Causes Foreign to Rheumatism — They are then almost always Mono-articular — Chronic Rheumatism, in the Majority of Cases, a Poly-articular Disease. Gentlemen : — We are now in a position to compare, from a pathologico- anatomical standpoint, chronic articular rheumatism with other diseases of joints which develop slowly. But, before we undertake such a comparison, it is indispensable that we should bring out the points of similarity existing between the changes in chronic articular rheumatism and those of the acute form. We shall very soon discover that the lesions of chronic rheumatism are, as it were, but a higher expression of those which occur in acute rheumatism ; they correspond to a more advanced period of the morbid action. The analogy we have" pointed out is not, at the first glance, a striking one, especially if we compare extreme cases, as for example, flying articu- lar rheumatism and morbus coxce senilis ; but it is manifested, on the other hand, most unmistakably when we choose for comparison those subacute cases that form, from a clinical as well as from an anatomical standpoint, a transition between the acute and the chronic form of articular rheuma- tism. I. — Changes in the Joints in Acute and Subacute Rheumatism. In the scholastic language of ancient medical writers, the term subacute was applied to acute diseases when they endured more than twenty-one days — this being the extreme limit to acute affections properly so-called — and they might extend over forty days. Pathology does not tolerate such arbitrary divisions, and, under the name of subacute articular rheumatism, we shall describe a disease whose development is, in truth, slower than that of acute articular rheumatism, and, moreover, diners from it in other respects, without, however, being radically removed therefrom. But, it 110 CLINICAL LECTURES ON must also be noticed, this subacute form is already allied to chronic artic- ular rheumatism because of certain of its characteristics. Thus, in this variety of the disease, the articular affections are more stable : fever is less intense, and resembles hectic fever ; the smaller joints are frequently affected, and oftentimes a large number of them. It is well known that in acute articular rheumatism the case is just the opposite. And, finally, visceral diseases, or at least certain classes of them, as endo- carditis and pericarditis, are here much less frequently observed. Such are the fundamental characteristics of subacute articular rheuma- tism. Later on in the course we shall present you with other considera- tions bearing on this subject ; but, for the time-being, we wish to indicate the lesions which are found in the joints in acute articular rheumatism, and also in the subacute form of this malady. There were interminable discussions, at a certain epoch, concerning the lesions of acute articular rheumatism. Can, or cannot this disease termi- nate in suppuration ? Some affirm that articular rheumatism never leaves a trace in the joints ; and others assure us that it produces most serious lesions, which may induce a purulent arthritis. To-day the question is considered to have been considerably exagger- ated on both sides, and a sounder appreciation of facts has resulted in establishing the truth of this opinion. True rheumatismal inflammation of the joints sometimes leaves behind it no appreciable change (Grisolle, Maeleod, Fuller), although, iu certain cases, on the other hand, it may result iu a purulent arthritis (Bouillard). But examples of this kind are very exceptional, and what we meet with in the vast majority of cases are the characteristics of an arthritis accom} by a sero-fibrinous exudation : the synovial membrane is red and vascular, and its cavity contains a serous fluid in which fibrinous floccules fl< For a long time it was thought that this was a completely superficial in- flammation, and that the synovial membrane alone was implicated < synovitis | ; but to-day it has been conclusively established that the cartilages, and even the bone, may participate in these changes. The synovial lesions will not long claim our attention : we have, a more or less pronounced vascularity of the fringe-like processes of the synovial membrane, which are present in the normal condition of affairs ; and, secondly, a varicose dilatation of their vessels (Lebert). The changes occurring in the cartilages possess a much greater impor- tance ; we are indebted for our knowledge of them to the interesting work of Ollivier and Ranvier. It has already been observed (Garrod) that the articular eartilag. quire sometimes a certain opacity, and lose their polished appearance, their blue color, and the consistence which characterizes them in a healthy condition. Ollivier and Ranvier have shown, besides, that frequently there are changes which can be appreciated by the unaided eye : such are the partial swellings on cartilage that give it a mammillated appearance, and sometimes even cause actual erosion. But, in cases where there is no change visible to the naked eye, the microscope yet reveals palpable and probably constant lesions. In the primary stage the most superficial ehondroK me globu- lar, and the cell which they contain divides, producing one or two second- ary cells. Thenceforth no alteration may occur in this condition, and we readily understand how, in such cases, the histological elements may return to their normal state ; but in a more advanced stage, there l ntation oi the THE DISEASES OF OLD AGf:. Ill fundamental substance in the horizontal direction — a kind of " velvety" con- dition marked by little furrows which penetrate more or less deeply into the tissue. In the interior of these little grooves of new-formation the capsules open and discharge therein the cells they contain ; these too are Fig. 14 Pig. 14. —Acute articular rheumatism : surface of a cartilage from the condyles of the femur. (After Ranvier.) The fundamental substance is transversely segmented ; the superficial capsules contain sev- eral secondary capsules ; only one remaining normal, enclosing a small cellular mass. Pig. 15. — Acute articular rheumatism: surf ace of the inverting cartilage of the patella. (After Ran- vier.) The primary capsules of this surface contain several secondary capsules; the fundamental sub- stance is transversely segmented ; an oblique strip, raised from the surface, remains floating. then seen to mingle with the synovial fluid, therein to undergo mucous metamorphosis. In this case there are, as you see, striking analogies with what occurs in arthritis deformans. But the changes which the bony surfaces present render the analogy yet more striking ; in certain cases they seem to take part in the phlegmasic action. According to Gurlt, 1 the marrow of the osseous extremities un- dergoes decided vascularization attended with cell-proliferation. Hasse a and Kussmaul 3 have also alluded to some alterations in the bone and peri- osteum occurring in acute articular rheumatism. A word yet remains to be said concerning the fluid contained in the synovial cavity. Sometimes it has an acid reaction, holding mucosin and albumen in 'solution ; fibrinous floccules are seen floating in it, along with clots of concrete mucus and globular bodies, some of which are cartilage- cells or epithelial cells that have undergone fatty degeneration, while others greatly resemble pus-globules ; and indeed, we occasionally find true pus- corpuscles in it. In general, however, it may be said that the latter ele- ment does not predominate, unless in those exceptional cases where there is symptomatic secondary rheumatism, or a rheumatismal arthropathy com- bined with the purulent diathesis. In fine, if we desire to interpret these phenomena, fibrin and pus-glob-* ules correspond to an acute synovitis ; while mucosin is produced by the transformation of epithelial cells and the fundamental substance of the cartilage. These changes, presenting unquestionable analogies with those of chronic articular rheumatism, are yet more strikingly similar in the case of the sub- acute variety. Thus, in instances where rheumatism had lasted nearly two months, I have found thickening of the synovial membrane along with dis- tinctly marked villous prolongations ; while erosions and a decided " vel- vety " change were met with at several points. On a subject who, on the twenty-fifth day, died after exhibiting cere- 1 Forster : Handbuch der path. Anat., p. 1000. I Hasse : Zeitschrift fiir rat. Med. Bd. V. , p. 199-212. 3 Kussmaul : Arch, fiir physiol. Heilkunde. Vol. xi. 1852. 112 fCLINICAL LECTUKES ON bral symptoms, Bonnet found similar lesions even then. 1 Vestiges of these alterations are still found in those who succumb to organic diseases of the heart, after having previously had several attacks of acute articular rheumatism. There is an imperceptible transition between these cases and those where the disease has become decidedly chronic, on account of the prolongation or the incessant return of the rheumatismal affection. Then there are more profound changes : synovial villosities are developed, foreign bodies are beginning to be formed, the articular surfaces are commencing to undergo eburnation, and there is a formation of bony vegetations around the joint ; finally the bone-tissue becomes friable toward the articular ex- tremities. Thus it is that we are enabled to prove, from an anatomical standpoint, the close connection binding the various forms of articular rheumatism among themselves. They are not different diseases ; they are varieties of one and the same morbid species. II. — Changes in the Joints in Certain Diseases, Independent of Rhkoia- And now a word with regard to the characteristics distinguishing ar- thritis deformans from other chronic arthropathies. First. — Arthritis from prolonged rest. — In the first stage, according to Tessier and Bonnet, 2 arthritis from prolonged repose gives rise to the fol- lowing lesions : there is a sero-sanguineous effusion into the joint, even fluid blood sometimes being found there ; the synovial membrane is inj- ecchymotic, and it is said there is sometimes even ulceration of the lages. But in a more advanced stage I have found that central ulcerations cut as cleanly as with a punch, and peripheral ulcerations existed upon the articular cartilages. There are no osseous swellings, no fibrous ankyloses, but there is a decided rarefaction of the boi. But tin characteristic of this arthropathy is the existence of a layer of connective tissue covering the articular cartilage throughout its whole extent ; this membrane is readily detached from the subjacent surface, and we then find cartilage whose cells in the chondroblasts have undergone fatty de- generation. This membrane is frequently penetrated by arboreseeir cularizations, sometimes advancing toward its central portions ; in this way are probably explained the vascularizations of cartilage described by cer- tain writers. I have found these lesions in patients who have long been stricken with hemiplegia or paraplegia, especially in those parts which re- mained uncovered, when articular deformity existed. Certain of these changes, you know, are found combined with thoe arthritis deformans in cases where the joint is absolutely at rest. Finally, we must acknowledge this to be an important question, one which, having as yet been little studied, demands further investigation. Second. — Fungoid, or scrofulous arthritis. — The investigations of Ban- vier 3 establish the fact that fungoid arthritis is widely separated from dry 1 Bonnet : Traite des Maladies des Articulations. Vol. i.. p. 32ft P*B ■ Tessier : Memoire sur les Effets de rimmobilite Longtemps ProIongM des A lations. Lyon, 1844. Bonnet : Op. cit., vol. i. 3 Ranvier: Des Alterations Histolosriques du Cartilage dans les Tumours Bla:. Paris, 1866. THE DISEASES OF OLD AGE 113 arthritis, even from a standpoint of elementary lesions. And this is proved by the study of the characteristic lesions of this disease. With regard to the bones and cartilages in arthritis deformans, there is a proliferation of the cell-elements ; in fungous arthritis, on the contrary, these elements are destroyed, and undergo fatty degeneration just as we see it occur in bone and in cartilage-cells. Besides, in a more advanced stage of the disease, the distinction is shown in the clearest possible manner ; fungoid arthritis gives rise to vegetations of bone and synovial membranes, attended by destruction and reabsorption of the cartilages ; and then supervenes caries or necrosis of the bone — peripheral abscesses, which surround the diseased joint, finally being formed. There are, nevertheless, analogies between these two affections. In certain cases of scrofulous arthritis there is active proliferation of the carti- lage-elements ; but this is a secondary occurrence. Sometimes there are <^> Fig. 16. — A section perpendicular to the surface of the articular cartilage of the femur : from a child With a white swelling. (After Ranvier.) The capsules at the surface each contain a little mass consisting of granulations that have accumulated within the cellular corpuscles. This is the change the cartilage un- dergoes at the commencement of the disease. also produced osseous stalactites, but these are extremely vascular (Bill- roth) ; there is a very decided difference between them and the thick, blunt-edgfed stalactites, formed like drops of candle-grease, and usually but slightly vascular, which characterize arthritis deformans. In this way the elementary lesions of the two diseases differ from each other, although there are mixed cases in which the two may be combined. Third. — Syphilitic arthropathies. — We now pass to the consideration of syphilitic diseases of the joints. It is extremely probable that by this de- nomination acute or chronic rheumatism occurring in the syphilitic has been described more than once, for these two diatheses are far from ex- cluding each other. A few clinical peculiarities, however, and the decisive influence of specific treatment in certain cases where the so-called rheuma- tism has been protracted, have induced some physicians, among them Babington, Boyer, and Lancereaux, 1 to think that there really exist special arthropathies as the direct results of a venereal infection. Lancereaux, to whom we owe a thorough and thoughtful work upon this subject, has carefully described the articular lesions of syphilis. He distinguishes two forms : (a) secondary arthropathies, which resemble acute or subacute articular rheumatism ; and (b) tertiary arthropathies, simulat- ing certain forms of chronic rheumatism ; the latter were the only ones he was enabled to study from an anatomical standpoint. They commence in the subsynovial cellular tissue and in the fibrous tissue, being character- ized by the formation of a neoplasm, which from its texture and external appearance absolutely resembles the gummy tumors (gummata). In those cases recorded by Lancereaux there was no alteration in the synovial membrane, although the articular cartilages were eroded. Fourth. — Gouty arthropathies. — The lesions of arthritis deformans fre- quently offer enough resemblance to those of gout to cause them to be easily confounded at the bedside ; but from an anatomical point of view 1 Lancereaux : Traite de la Syphilis, p. 182. 1866. 8 114 CLINICAL LECTURES ON this is not the case. You never find the least trace of a deposit of urate of soda, either in the articular diseases which arise from rheumatism, or in the other arthropathies we have just enumerated. This uratic infiltration of cartilage is, then, the essential characteristic of articular gout ; and besides, there is here no other constant lesion of the cartilage. There is no segmentation of the fundamental substance, and there is no cell-proliferation, so that if the two changes are found existing simultaneously there is evidently a juxtaposition of the two diseases. They never undergo a transformation that permits of their being confounded. 1 Fig. 13. Fig. 17. • Fig. 17.— Section perpendicular tn the articular surface : from a gouty cartilane. (After Cor- articular surface; v, n, group of cartilaginous cells infiltrated and poda; o, normal cartilaginous capsule, in contact with crystals formed in the fundamental robots the cartilage. (Magnified two hundred diameters.) Fig. 18.— A partly schematic representation of the dissolution at unite* encrusting a cartilaginous cell by the action of acetic acid. (After ComiL) c. oartflaginoufl capsules bristling with free crystals ; oli ing rise to infarctions having a cone-like form. I rd the hilum, after the well-known manner of distribution of the in thi-j organ. We ourselves had an opportunity to observe an ii. this lesion manifested itself in consequence of a rb< umatic affection i heart. The patient whs a man, twenty-four y< tacked with acute articular rheumatism and then witi. During life he had a double "rasping " murmur at 1 1 complained of intense pain in the region of t .. which acquired considerable size, lb died with the orduD disease. At the autopsy fibrinous vegetation semilunar valves, and two fibrinous A woman, seventy-on. l: suffered fro t articular rheumatism and puhn with intense dyspnoea and elicits a slight inoreaee in the ana • nesa, and on ausculta- tion we hear half of the sternum, where it mask- nial heart influence of appropriate n six weeks, after having lations that were already dianaa This case may be oompared to service at theSainte-Eu chronic articular rheumatism, .. sounds in the precordial region. 1 long. The rheumatism in the pericarditis; and sube highest degree, all the ehar Since the period when my atl frequently m en oases ol pi ricarditi the exacerba arthropathies in : | with ehi stances I have just record, observations. To sum up. then, endocarditis and | c>ccur m some cases of chronic articular rheumatis] exhibit the same char* • absent in , umatiam. They occur preferably during the period . it somewhat approzhna diseases are, m general, of a less serious nature when a chrome articular rheumatism. 1 Cornil : Momoiro sur 1, noe « Patbolojriquet du Kheamatiam« ArticuUire Chromque. Momoirea de la Soc! irth *x£.**L It. 18* THE DISEASES OF OLD AGE. 131 LTI. — Some other Abarticular Diseases in Chronic Eheumatism. Cardiac affections are not the only visceral manifestations of the rheuma- tic diathesis. Let me remark, however, that it is important to observe that the other usual complications of acute articular rheumatism are more rarely met with in the chronic variety than endocarditis and pericarditis. But, on the other liand, we shall soon learn that certain affections accompany the chronic form that are almost wholly unknown to the acute, as one would naturally surmise. In this connection we shall rapidly review the principal systems of the economy. The Respiratory Apparatus. — Pleurisy occurs in subacute and chronic articular rheumatism, but it is much rarer than in the acute form. e pneumonia is a frequent complication of acute arthro-rheumatism ; I have never met with it in the chronic form. I have certainly seen some s of chronic pneumonia in rheumatic patients, but the latter were cachectic. Rheumatic pulmonary congestion, that dire condition rendering the pa- tient liable to sudden death, may be encountered in subacute or chronic rheumatism. Dr. Ball records a very remarkable case of this kind in his "Tb a -ation." ' Certain thoracic affections occur especially in chronic and ill-defined forms of articular rheumatism. . followed by emphysema, is as com- mon in this disease as in gout I have seen this complication twice in lip triere. The firai case was that of a woman, sixty years old, who for twenty-five i a washerwoman. Her asthma dated back ten years. At first the attacks were few and noc- turnal. At the time of recording the ease the paroxysms were so closely re- current, so commingled, that the patient passed the greater part of both day and night sitting on the bed, breathing with intense difficulty and distress. There were always sibilant rales that could be heard at a distance, and auscultation showed great feebleness of the vesicular murmur over the entire surface of both lungs. The expectoration was scanty. This woman never had been attacked with acute general articular rheumatism ; but several times, during a period of seventeen years, she had arthritic pains accompanied by swelling of the joints. The parts principally affected were the knees, shoulders, and the metacarpophalangeal joint of the index finger of the right hand. There were no characteristic deformi- ties in thifl oaae, but a well-marked "crackling" noise was observed upon motion of the knees.* The second case was that of a woman, sixty-six years of age, who after having lived for a long time in a very damp lodging, seemed to have had an attack of acute articular rheumatism. She remained in bed for six weeks, and two months after she got up she could not walk without crutches. Since that time there were occasional attacks of lumbago and flying artic- ular pains. At the age of forty there was a new attack of subacute artic- ular rheumatism. A last attack of the same kind occurred four years be- fore she came into the service. The menopause occurred in her fifty-sixth year, and it was a short time after this that oppression and a sense of constriction appeared. At the 1 Op. cit., p. 61. - Op. cit., p. 129. 132 CLINICAL LECTURES ON commencement of the pulmonary disease, she was for nearly two months unable to lie upon her bed. The attacks, always of long duration, were at first considerably remote from one another ; then they drew nearer and nearer together, so that, for about three years, the oppression and constric- tion became permanent, and were much increased by walking. When the thoracic disease assumed such a degree of intensity, the ar- ticular pains became vaguer and more flying. There were no deformities of the joints ; but very distinct " crackling " in the knees. After quite a long stay in the infirmary, this woman died, an extensive oedema of the lower limbs meanwhile having been developed. The autopsy revealed : First. — Hypertrophy of the right ventricle, without any valvular lesions, and without a trace of old or recent pericarditis. Second. — Articular lesions, almost identically the same as those of acute articular rheumatism, but without synovial effusion into the joint, and a much stronger-marked velvety condition of the osseous surfaces. TJiird. — Well-marked redness and evident vascularity of the mucous membrane of the bronchi as the pulmonary lesions ; these tubes con- tained a considerable quantity of greenish and tenacious mucus. This woman's son has long been asthmatic. 1 It is clear that in this interesting case there was first an acute articular rheumatism, and then a subacute, which finally ended in the chronic form. The coincidence of asthma with articular manifestations in this patient is of capital importance from the standpoint whence we are now considering the subject. The existence of a laryngitis allied to acute rheumatism has. you know, been pointed out long ago. Garrod has described in addition a particular form of chronic laryngitis occurring in nodular rheumat Has pulmonary -phthisis any relation to clironic rheumatism? Tl still a mooted question, and one that we purpose I rthei on in the course. Urinary Apparatus. — In acute rheumatism there is a special neph which we have just described. Kidney-changes are almost the rule in gout. In chronic rheumatism albuminous nephritis is quite frequent in the advanced stages, according to the in v. - 3 which, together with Cornil, I made concerning this matter. 1 re always met with in those who are markedly cachectic. Vesical implication is quite rare in acute articular rheumatism, gout, and those burning pains experienced by rheumatic subjects during micturition, must not be confounded, the last-named sensations arising from extreme concentration of the mine. In chronic rheumatism, on the contrary, cystitis is quite frequent, pecially in those who have long been confined to their I The Nervous System. A. — Cerebral diseases. — We have described the striking analogies between rheumatic encephalopathy and the cerebral symptoms accompany- ing gout. Rheumatic insanity, described by Burro wa, Mesne t, and ciriesin- ger, is quite often associated with the subacute forms of rheumatism. Symptoms of this kind, in chronic rheumatism. hav t scribed by Fuller and Vidal. But these cases are quite rare. 1 This case is recorded, but incompletely, in Dr. Ball's t: THE DISEASES OF OLD AGE. 133 Megrim, so common in the intervals between the attacks of gout, is also present in the course of chronic rheumatism. 1 B. — Medullary affections. — Chorea, whose relationship to acute articular rheumatism is so well established, does not seem to be present along with the chronic form ; at least I have never seen it "occur in the latter disease. Several diseases, however, that arise in the spinal marrow, are met with in the chronic variety of rheumatism. Paralysis agitans, or, at any rate, the tremor, sometimes accompanies partial or general chronic rheumatism. I have seen several cases of locomotor ataxy coincide with dry arthritis or nodosities of joints. But, since we now know that the arthropathies of ataxics may manifest themselves at the beginning of the disease, it becomes extremely difficult to estimate the exact part played by the rheu- matic diathesis. 2 As for paraplegia, it is rarely present in either acute or subacute rheu- matism, and we must be well on our guard against confounding articular pains of spinal diseases with rheumatism in the joints ; for lesions of the spinal cord occasionally induce painful swellings of the articulations, as Mitchell, Morehouse, Remak, and several other observers attest. Certain lesions yet remain to be described, which, though not located in the internal viscera, are still abarticular. We have seen that gout sometimes causes affections apart from the joints, besides its visceral diseases ; and it is the same in the acute and chronic forms of rheumatism. Thus, the muscular pains of gout, followed by cramps and retraction of the muscles (Guilbert), may likewise be met with in acute rheumatism ; but they are much more frequent in chronic rheumatism. Sciatic and trifacial neuralgice, although occurring equally in gout and rheumatism, yet especially belong to the subacute and less intense forms of both diseases. They may also be met with in Heberden's rheumatism ; Dr. Bastian communicated a case of this kind to me. The visual mechanism may be affected in rheumatism as well as in gout. We have already spoken of gouty iritis and sclerotitis. Eye-affections are rare in acute rheumatism ; but it is quite the contrary in subacute (Garrod, Puller) and chronic rheumatism (Cornil). There is generally an iritis, but obstinate cases of conjunctivitis may also occur. A palpable alternation Taetween the ocular phenomena and the symptoms referable to the joints is frequently seen. Finally, skin diseases, so well known in gout and acute rheumatism, are also met with in chronic rheumatism. They are not very common in the intenser forms of this disease, being principally encountered in partial chronic rheumatism. Bazin observed, also, that cutaneous diseases are the more tenacious and obstinate the less marked are the arthropathies. We have very frequently found the skin diseases described by Bazin in chronically rheumatic patients : eczema, numular psoriasis, lichen, and ar- thritic prurigo. Indeed, we have often seen erysipelas allied to nodular rheumatism. In our next lecture we shall take up the symptomatology of chronic irheumatism. 1 On this subject consult Dr. Malherbe's thesis, p. 45. Paris, 1866. a Charcot : Archives de Physiologie, p. 162. 1868. 134 CLIiaCAL LECTURES ON LECTURE XV. SYMPTOMATOLOGY OF CHRONIC PROGRESSIVE ARTICULAR RHEUMA- TISM. Summary. — Three Fundamental Types of Chronic Articular Rheumatism — In Reality Constituting but One and the Same Disease — Chronic Progressive Articular Rheu- matism, or Nodular Rheumatism — Frequently Confounded with Gout, from which it Essentially Differs — Is Preferably Located in the Smaller Joints. Arthropathies arising from Nodular Rheumatism — Often Kesemble. at the Com- mencement, those of Acute Rheumatism —Spasmodic Retraction of Muscles — Al- tered Positions, Attitudes \ tcit uses— Permanent Disorders — Pain — Crackling — Bony Deformities— Joints which are Preferably Affected — The Hands almost always the First Attacked— Symmetrical Invasion — Mode of Succession of Ca- Arthritis — In Young Subjects, frequently Generalized from the Commencement — In Older Patients has a Progressive Course — Consecutive Deformities of the Limbs — Two Principal Tj'pes, their Varieties. Progress of the Disease — Secondary Changes — Atrophic Form — (Edematous Form — Loss of Movement. Deformity of the Lower Limbs— Of the Vertebral Column — Deviation of the Head — General Invasion of all the Joints. Mode of Production of these Lesions — Various Opinions — Spasmodic Contrac- tions — Accessory Causes. General Symptoms— Hematology — General Reaction — Rapid Development — Slow Development. Gentlemen : — Until now -we have regarded chronic articular rheumatism in only one of its aspects. The pathological anatomy of this disease has been, until the present moment, the object of our study ; but it is time to enter upon the clinical view of the question, and to present you with the symptomatic evidences that reveal the existence of this affection. We have already dwelt upon the necessity of recognizing at the outset three fundamental types in respect to anatomy ; and it seems equally ne- cessary to establish this distinction in regard to symptomatology. The division is, as you already know, 1st, nodular rheumatism, or prog 1 , chronic articular rheumatism ; 2d, partial chronic articular rheum:, and 3d, Heberden's rheumatism. These are not three distinct diseases, but three particular forms of one and the same affection. It is none the less indispensable to separate theni, for the nature and chain of symptoms, the prognosis, and even the treat- ment, varies in each of the three types of chronic rheumatism. We shall devote this lecture to progreoiive c hr o nic articular rheumatism. From a medical point of view, nodular rheumatism is the most int< ing of the three types we have enumerated. Often mistaken for gout, it has sometimes received the name of gouty rheumatism. "We have ah demonstrated to you that a radical distinction must be made in t!. srject. Rheumatism ought never to be confounded with gout ; but all the varieties of articular rheumatism are part of one and thl species, and should be assigned to the same category. THE DISEASES OF OLD AGE. 135 Nodular rheumatism is to the other forms of chronic rheumatism what acute general rheumatism is to the subacute or partial variety. It espe- cially affects the smaller joints, those of the hand in particular. It is a dis- ease that too often defies all the resources of our skill, and gives rise to deplorable infirmities. We shall first describe the arthropathies induced by this disease ; and secondly, the symptoms arising from the constitutional condition. 1. Arthropathies. — In the first stage the articular phenomena — if we ex- cept their locality — differ in nowise from those in acute or subacute rheu- matism. The affected joints are the seat of pain, redness, heat, and swelling — the same characteristics as in acute rheumatism ; but here the symptoms are much less intense, and are infinitely more stable. Let us also observe that there is no oedema, no desquamation, as we have in gout. This train of symptoms, however, is frequently joined by a new phe- nomenon, even at the very commencement — a phenomenon which is far from appearing with the same degree of intensity in the acute form : we mean that spasmodic contraction of the muscles which produces such strange and sometimes permanent distortions of the diseased members. In the second stage we have the development of lasting disorders. Tumefaction has occurred in the soft parts, productive sometimes of an hydrarthrosis, sometimes of a thickening of the synovial membrane and subserous tissue; it has likewise occurred in the hard parts, and then we observe the development of osteoids or foreign bodies, common enough in some joints, though rare in others, the osseous swellings deforming the heads of the bones, and finally, subluxations of the articular extremities. The pain, either spontaneous or induced, now becomes permanent ; it may be located in the articulation itself, the body of the bones, or the ad- jacent muscles, in the form of agonizing cramps. Then it is that we hear the crackling or crepitation due to the eburna- tion of the bony surfaces, if the joint still preserve a certain degree of mo- bility ; although very often the rigidity arising from fibrous ankylosis and retraction of fibrous-tissue becomes perceptible likewise at this epoch. Lastly appear those bony deformities that follow certain laws and rules, which we shall consider farther on in our course. And now let us see what joints are preferably invaded. This disease, as we have already said, has a predilection for the smaller joints. The larger articulations are attacked only in advanced stages of the disease, al- though even in cases of a general implication, the shoulder and hip are frequently spared. You must bear in mind, however, that the upper ex- tremities are almost always the first attacked ; this is just the reverse of gout, in which the upper limbs are only secondarily affected as a rule. Nodular rheumatism's mode of invasion also presents distinctive peculi- arities. Symmetry is here the rule, as Budd observes, a statement con- firmed by Komberg, and also verified as to its accuracy by myself. Gout, as you know, is far from following any such course as this. Let me re- mark, however, that in a few exceptional cases chronic rheumatism is asym- metrical, and the rarity of this occurrence induces me to call attention to it. In this instance one side of the body is first attacked, and subsequently the articular lesions become generalized. A distinction no less marked exists between gout and nodular rheuma- tism in regard to the parts that are first attacked. In gout it is the great toe ; in nodular rheumatism the metacarpophalangeal articulations of the index and middle fingers are the first invaded, and this, too, on both sides 136 CLINICAL LECTtTPwES ON of the body simultaneously, in conformity to the law of symmetry we have enunciated. Do not forget, however, that this disease begins in a large joint much more often than gout, and this fact alone frequently aids us in making a diagnosis. In connection with this question let me adduce also a few statistics : First. — Hands and feet alone, smaller joints 25 times. First. — — — — — The great toe 4 times. Second. — Hands and feet along with a large articulation . . 7 times. Third. — A large joint at first, and later on the fingers. ... 9 times. Let us now look at the mode of succession of arthritises in nodular rheu- matism. In the majority of cases they develop from the periphery toward the centre ; the fingers are first implicated, then the elbow, then the shoul- der. This regular succession, however, is met with only in those cases where the disease develops slowly. In young patients, from sixteen to twenty years of age, this affection, on the contrary, is often general from the outset ; but in older subjects, from forty to sixty, it follows the progressive course we have just described. In the first case the disease is evolved rap- idly ; in the second it develops slowly. But nothing is absolute in this re- spect, since often, at the menopause, the symptoms occur abruptly and the malady presents all the traits of an acute disease. We have yet to describe the deformity of the limbs that results from this morbid action. They are especially marked in young subjects when spasmodic pains are present and muscular retractions are excessive. We do not speak now of deformities of the joints themselves, but of the faulty positions arising from a change in the relation between the various seg- ments of the limb. These deformities are almost always identical ; they obey regular laws. In the case of the upper extremity they may be divided into two principal types, with secondary derivatives. In both cases the hand is more or less exaggeratedly pronated. This characteristic belongs to each in common ; but they diner in many other respects. We shall give a succinct description of all of them. First type. — This is the one most frequently met with. It is characterized : fl. — By flexion at an obtuse, right, or even acute angle of the terminal phalanx upon the middle phalanx. b. — By extension of the middle phalanx upon the proximal phalanx. c. — By flexion of the proximal phalanx upon the metacarpal beads. d. — By flexion, at a less obtuse angle of the metacarpus and carpus upon the bones of the forearm. e. — In a great number of cases by an inclination, en mane, of all the phalanges toward the cubital (ulnar) side of the hand, and then a twisting in the opposite direction of the middle upon the proximal phalanges. The former of those two lesions is often one of the first deformities the advent of this disease. This type presents two varieties. In the first, most of the cbaraeti tics we have described are preserved ; but the proximal and middle phalan- ges are in the same plane, have the same axis, and form a single column. In the second, flexion of the terminal upon the middle phalan. sent, and then the fingers seem hollowed or excavated, starting froin the projecting metacarpal heads. THE DISEASES OF OLD AGE. 137 Second ft/pe.^This is marked : a. — By extension of the terminal phalanx upon the middle phalanx. Fig. 20.— First type. b. — By flexion of the middle phalanx upon the proximal phalanx. c. — By extension of the j^roximal phalanges upon the metacarpal heads. 4J=E Fig. 21.— First variety of Type 1. d. — By a more or less pronounced flexion of the carpus upon the bones of the forearm. Fig. 22. — Second variety of Type 1. e. — In certain cases, by a deviation, en masse, of the proximal phalanges, which are visibly inclined toward the ulnar side of the hand. Fig. 23. — Second type. 138 CLINICAL LECTURES ON This type, like the preceding, may present two varieties. In the first, there is flexion of all the articulations of the hand, consti- tuting, after a fashion, a kind of scroll. Fig. 24.— First variety of Type 2. Fig. 25.— Second variety of Type 2. In the second we observe the same thing, except that, in addition, there is extension of the middle upon the proximal phalanges. Hitherto we have only considered the deviation of the fingers of the hand ; what becomes of the thumb ? Here, as elsewhere, the metacarpophalangeal articulation is especially altered. The first phalanx of the thumb is often flexed, though sometimes extended. The other articulations of the upj)er extremity partake, in a certain measure, in these deformities. Thus, flexion of the elbow is more or less marked — indeed, is sometimes exaggerated ; extension is impossible. The forearm is pronated. There is more or less complete flexion of the carpus and the metacarpus upon the forearm, with projection of the ulna and radius. Finally, the shoulder is sometimes rigid, and the whole upper extremity is fixed against the thoracic wall. We shall next consider in what manner, and in what order, the articula- tions of the upper extremity are invaded. Two cases may present themsel A. — In young subjects the disease progresses rapidly, and spasmodic contractions of the muscles being very marked, the deformities are distinctly exhibited. There is projection of the heads of the bones following upon subluxations that have occurred in the joint. Thus, in the second type, there is considerable projection of the bones of the forearm behind the carpal bones ; there is a subluxation of the heads of the proximal phalanges, in front and to the outside, producing quite prominent projections upon the back of the hand ; and there is a slightly marked subluxation of the middle phalanges forward upon the proximal phalanges, the heads of which bones bulge upon the palm of the hand. Finally, on account of prolonged flexion of the terminal upon the second phalanges, the small condyles of the latter project behind. Attention must bewailed to the fact that the osseous vegetations around the digital ai lations do not constantly circumscribe the heads of the bones : sonu I there are tubercles, sometimes more or less elongated needles. At am these osteophytes contribute but slightly to the deformity of the joint* ^ And lastly, in the form we are discussing, there is more complete immo- bility, on account of the greater rigidity of the ligaments and fibrous tis- sues : fibrous ankylosis soon results, and thus a rapid wasting of tlu is induced. The term nodular rheumatism is scarcely applicable to otfl this sort. THE DISEASES OF OLD AGE. 13 9" B. — In older subjects the disease develops more slowly, and the power of movement is partly retained. Deviations from the normal are much less strongly marked, and the size of the heads of the bones and of the os- seous stalactites is greater. There is, in reality, a sort of inverse proportion between the degree of deviation and the size of the bony swellings, as well as the extent of the deformities resulting from the latter. "When the disease is prolonged beyond a certain period of time, changes are produced which are the results of this state of affairs. Atrophy of bone, atrophy of muscles and wasting of the soft parts are the commonest occurrences in such cases. We can distinguish, however, two opposite forms here : in the atrophic variety (Vidal) there is induration of the skin — a kind of scleroderma : the cutaneous investment is cold, pale, smooth, and shining, no longer wrink- ling. In the other form an oedematous infiltration, simulating elephantiasis, occurs in the member, and this swelling is frequently accompanied by in- flammatory symptoms ; these phenomena are especially manifested in the lower limbs. In all cases the muscles of the limbs finally undergo a cer- tain degree of atrophy and fatty degeneration on account of the immobility of the parts. The immediate result of these changes is that the patients are debarred of movement in the upper extremities, and are no longer able to feed them- selves. Then appear those ingenious inventions — those long forks whose form and dimensions vary according to the infirmity of the sufferer, but whose object is always to enable them to convey food to the mouth, thanks to the more or less restricted power of movement they still possess. In this connection let me remark that the right hand, with which the patients continue to feed themselves, does not present in its deformities so regular a type as the deviations in the left, which, in the vast majority of cases, becomes absolutely immovable. And now let us look at the articular lesions that may occur at other points in the skeleton. The lower limbs are occasionally free from implication, and this when the hands have suffered the most marked changes. But such cases are rare, and generally the lower limbs are deformed symmetrically ; there is deviation of the segments, and they become incapable of producing ordi- nary movements. The hip-joint usually preserves its freedom, but the same cannot be said of the knee. In the majority of cases there are flexion of the thigh upon the abdomen, and flexion of the leg upon the thigh. The principal deformities are as follows : The lower end of the femur projects in front of the head of the tibia. The internal condyle of the femur becomes protuberant. The patella, thrown to the outside, rests upon the external condyle. The head of the fibula projects backward. Complete ankylosis at the knee-joint is, however, a rare occurrence ; but bony swellings are almost always developed there, and foreign bodies may be met with in great abundance in this locality. In the tibio-tarsal articulation, on the other hand, ankylosis is very fre- quent. The foot may be abducted, then resting upon the external border, 140 CLINICAL LECTURES ON thus simulating talipes valgus; and it may, on the other hand, be carried in abduction : then we have a talipes equino-varus. 1 The great toe is carried outward so that it covers the other toes. Important deformities may likewise occur on the part of the cervical vertebras. In several cases that I observed myself in the Salpetriere, I have seen the head bent forward and flexed upon the sternum, so that the chin nearly touched the chest. The movements of the head were very limited, and caused crepitating or crackling sounds when attempted. In the major- ity of these cases the neck was noticed to be enlarged posteriorly. And it is in this way that most of the joints may be attacked in one and the same individual, in a case of general chronic rheumatism ; and then the unfortunates are condemned to remain in bed during the remainder of their existence. They sometimes live more than twenty years in this mis- erable condition. The mode of production of these deformities yet remains to be studied. Some physicians ascribe them to a providential action (Beau) which aims at palliating the intensity of the pain ; others believe them to be the result of attitudes which the patients instinctively assume (Trastour). I profess, myself, a diametric-ally opposite opinion on this subject. In the majority of cases these deformities come from spasmodic, and, as it were, convulsive, muscular contract tons. They are produced by a sort of reflex action whose starting-point is in the diseased joint I shall not dwell long upon this subject. The arguments that I have previously advanced, reinforced by those of Crocq, appear to me to have incontrovertibly proved that these results are produced in precisely this manner. In this regard we may adduce : Fii'st. — The very form of the deviations or deformities ; they are mani- festly forced actions. Second. — The resistance that the patients offer to these spasmodic retrac- tions, which, although impotent to prevent them, is sufficient proof that they are involuntary. Third. — The general aspect of the deformities, which certainly accords with idea of muscular spasm : they are, indeed, deformities or deviations as a whole, even when the joints brought into play are not all implicated. Fourth. — Finally, the presence of the same deformities in cases where the joints are in nowise affected ; they can then be ascribed to the spasmo- dic contraction of muscles alone. Thus, in paralysis agitans, in congenital cerebral atrophy and in atrophy of the interosseous muscles, the parts occasionally assume a form in every respect the same as that observed in chronic articular rheumatism. Moreover, it would be impossible to deny the existence of accessory in- centives in addition to the fundamental cause of rheumatic deformities. The weight of the limbs, the greater or less laxity of the ligaments, have a correspondingly important part to play in the production of these deviations from the normal ; but these various conditions are insufficient in theme to induce similar' effects without the concurrence of muscular* retraction. Do we not see in certain cases of hydrarthrosis exceedingly great laxity of 1 This is an exact and almost literal translation of the original paragraph. I think the word external should be internal {interna in place of extern*^ and that ti Eduction should read Eduction. — L, H. H. (See Eriohsen'fi Sundry. >e\ enth edition. Vol. ii., pp. 309-371 inclusive.) THE DISEASES OF OLD AGE. 141 the ligaments of the knee, without any subsequent deformities resulting therefrom ? On the contrary, the part remains absolutely flaccid. As we have seen, the deformities that have just been described do not belong exclusively to rheumatism. But the changes in the joints, the crackling or crepitation, the hydrarthrosis, the fibrous ankylosis, and con- sequent rigidity of the articulation, the symmetry of the lesions — all these distinguish the effects of chronic rheumatism from those produced by par- alysis agitans and various other diseases. But gout gives rise to the same spasmodic contractions, and to the same deformities and deviations. In his " Treatise on Gout," Guilbert has dwelt at length upon these muscular retractions. The presence of tophi, however, which accompany in the majority of cases this kind of deformity in the gouty, is a truly pathognomonic charac- teristic. In rheumatic patients nodosities occasionally perforate the cuta- neous investments ; but the part exposed is bone, and not a chalk-stone, as in gout. General Symptoms — Course of the Disease. A. — Hematology and a chemical study of the secretions have as yet given only negative results. Musgrave says the blood is buffed (couenneux) ; it certainly is in the acute forms, but we never find any uric acid in it. I have, myself, exam- ined the blood in thirty-five cases of chronic articular rheumatism, without ever discovering the least trace of this substance. In a case reported by Bocker, the chemical analysis furnishes most in- teresting results. This case is cited as one of gout, but it may certainly be attributed to nodular rheumatism, for the extremities of the bones were swollen — a thing that never happens in gout. The blood and the urine were examined, and in the urinary secretion there was a marked diminution in the normal proportion of phosphate of lime, while, on the contrary, the blood contained four times more phosphate of linie than normally present. It appears that the ordinary quantity of uric acid was not increased— at least, the author is silent upon this point. B. — From a standpoint of general reaction and the progress of the dis- ease, we have to recognize two essentially distinct forms. In chronic articular rheumatism that develops rapidly, the disease is usually in young subjects froni sixteen to thirty years of age, or in women who are pregnant or in the puerperal state ; moral emotions and impres- sions of intense cold may likewise exert a certain amount of influence. In such a case we see a large number of joints simultaneously attacked. Muscular retractions are more pronounced, pains are very severe, red- ness and swelling are quite marked, and the disease is less unstable than in its opposite type. The general symptoms are those of acute or subacute articular rheuma- tism ; we notice marked elevation of the temperature, manifest acceleration of the pulse and profuse perspiration. It is in these cases especially that cardiac affections are met with. It might be admitted here that rheumatism, at first acute, has later on assumed the chronic form ; this opinion, which has been upheld by vari- ous writers, may be true in a few cases. Dr. Ball brought me a patient in whom the metacarpophalangeal articulations were attacked during the 142 CLINICAL LECTUBES ON course of an attack of acute articular rheumatism. The result was a devia- tion of the fingers toward the ulnar side of the hand ; and this man, who to-day remains wholly recovered, still carries these characteristic deformi- ties of nodular rheumatism. We think, however, that, in the vast majority of cases, such examples are chronic rheumatism from the outset, but that the course of this chronic form presents some of the characters of acute rheumatism. After a certain period of time, a remittent fever is developed, resembling hectic fever ; and then we witness the occurrence of a series of exacerba- tions followed by long intervals of remission. In cases of this kind the disease usually lasts but for a comparatively :short time. After two, three, or four years the joints almost completely cease to be painful, and the case remains, then, in that condition. Some- times, indeed, these deformities cease to exist after having been produced. We have observed cases of this kind ourselves ; unfortunately, they are only too rare. In this way, also, a woman who was at first attacked with sub- acute febrile rheumatism affecting the shoulders and the nietacarpo-phalan- geal articulations, three months after the commencement of the di suffered spasmodic retraction of the fingers ; this secondary deformity lasted during an entire year, and then the patient recovered. Chronic rheumatism that develops dotdy, generally occurs in older subjects, from forty to sixty years of age : this ten met with it the time of the menopause. Geist ' described this fomi under the name of senile gout. It is here especially that we meet Haygarth's m the joints. One by one the articulations are invaded in succession ; in these c therefore, the mode of invasion can best be studied. Pain is ]. and there is less redness ; indeed, it is often wholly wanting. The devia- tions resulting from muscular contractions are less marked, but, on the other hand, the deformities of each joint are much more prominent. Concerning the general bodily condition, it may be said that it is but rarely accompanied by febrile movement ; only from time to time rise in the temperature observed. Finally, taken all in all, the prognosis is not so grave as in the preceding form. We have compared these two extreme varieties in order to expose their analogies and their differences, but between these two forms there is a num- ber of intermediate stages, establishing a gradual transition. Let me remark, too, that, notwithstanding the rule which we have enunciated, cases are met w T ith in younger subjects that are the counterparts of those occur- ring in the aged : and the converse also holds good. Klinik der Greisenkrankheiten. Erlangen. THE DISEASES OF OLD AGE. 143 LECTURE XVI. SYMPTOMATOLOGY OF PARTIAL CHRONIC RHEUMATISM AND OF HE- BERDEN'S NODOSITIES. Summary. — Partial Chronic Rheumatism — Various Denominations it has Received — Does not Essentially Differ from Nodular Rheumatism — Its Particular Character- istics — Small Number of Joints Affected — Larger Articulations oftenest Involved — Insidious Advent — The Form Chronic from the Commencement — Articular De- formities — Diathetic Manifestations — Cutaneous Diseases — Visceral Affections. Mode of Development — Occasionally succeeds Acute Rheumatism — May show Itself at the Beginning- — Sometimes Generalized. Articular Phenomena — Deformity — Pain — Absence of Sensibility on Palpation — Crackling or Crepitation. Prognosis Comparatively not Serious — More or Less Complete Abolition of Movements — Spasmodic Retraction of the Muscles quite Rare — Extreme Rigidity of the Articulation. Nodosities of Heberden — Independent of Gout — Are Located around the Articu- lation of the Terminal Phalanges — Lesions are Identical with those of a Dry Ar- thritis — Other Joints of the Hand frequently Involved, but to a Less Degree — This Affection Accompanies the Rheumatic Diathesis — It may, though very rarely, Coincide with Gout. Gentlemen : — We shall complete the description of chronic rheuma- tism's symptoms by a study of the two chief forms of this disease following upon nodular rheumatism, in the classification we have adopted. We mean partial chronic rheumatism and Heberden s nodosities. Partial chronic rheumatism, to which we shall first devote our attention, has received a large number of appellations varying with the different writers upon the subject. When located at the hip-joint, it is called mor- bus coxae senilis ; it has been denominated senile arthritis, and dry arthritis, when it had its seat elsewhere. It is the disease that produces the most characteristic deformities : it is arthritis deformans. This disease does not essentially differ from the preceding ; it is marked, however, by a few peculiar symptoms. Several of these we have already described. And now we wish to recall the most characteristic differences that separate these two forms of one and the same disease. First. — A small number of the joints is involved, in comparison with what occurs in general rheumatism. Second. — The larger joints, and even those which, in the preceding form, only suffer in very rare instances, are here the ones oftenest attacked. Third. — The form that is chronic from the onset is here the rule. In the majority of cases it begins insidiously ; pain is not very marked, and the affected members usually preserve their mobility — that is, to a certain extent. But, on the other hand, considerable deformity frequently occurs about the joints, on account of the exuberance of the osseous swelling ; and besides, we sometimes meet with an hydrarthrosis sufficient to aid in the deformity. (Hypertrophic form of Adams.) 144 CLINICAL LECTURES ON This disease has been especially studied from a standpoint of external pathology, and investigators have more especially devoted their attention to those cases where the disease was localized in a single articulation. In- deed, the diagnosis may then present the greatest difficulties ; for this form of rheumatism may simulate a luxation, a fracture, and still more, a white swelling. These are questions that have always attracted the atten- tion of surgeons ; nevertheless, the study of this disease possesses a great interest for the physician — indeed, it involves the question of a disease almost always diathetic, which may frequently be accompanied by cutaneous affections, 1 and by visceral lesions (asthma and cardiopathies) whose sig- nification is shown by the very fact of their coinciding with chronic arthrop- athies. It may be observed, besides, that the localization of the disease in a single joint, the latent development of the malady and the extreme preva- lence of bony swellings of new formation, are facts that are rather the ex- ception than the rule, and facts that are especially striking from their very rarity. The arthropathies of partial chronic rheumatism very frequently appear with all these characteristics — in a very inferior degree, it is true, but nevertheless perfectly appreciable. This fact is of great clinical importance, for the well-established existence of these arthropathies may become an easily comprehended index of the rheumatic diathesis ; and it is from this point of view that it is of significant interest to us. I shall not undertake, gentlemen, to give you a description in due order and form of this variety of rheumatism ; it belongs especially, as I have said, to the domain of surgery, and on that ground I do not wish to en- croach. But I must needs acquaint you with certain of its characteristics, which, considered from the standpoint we have taken, j>ossess the highest importance for us. A. — Chronic partial rheumatism occasionally appears to succeed acute articular rheumatism, and thus becomes its consequence. Adams, who has made a special study of this question, recognizes this mode of development of the morbid phenomena. In such circumstances it is one of the forms of node-articular rheumatism. Two varieties may oc- cur : sometimes the rheumatism degenerates into a white swelling ; some- times it assumes the characters of arthritis deformans. The latter happens oftenest, and in this transition there is nothing to excite any surprise, since we know that acute rheumatism has, at its inception, the lesions of the chronic form. B. — The commencement of arthritis deformans may be acute, while the rheumatism is partial from the onset. Adams : and Colombel s record ex- amples of this, and I have myself observed a few such cases in 1 * riere. Thus, a woman fifty-three years of age had. at the beginning, acute partial arthritis, with fever and muscular retraction ; then the disease pen under the form of a dry arthritis ; finally symmetrical pains occurred in both hands, and the disease passed into nodular rheumatism. C. — On the other hand, the disease, as we have already seen, may con- mence slowly and insidiously, the symptoms remaining localized in a sin- gle joint from the start ; but the real nature of the disease is in the end revealed by one or more arthritises, or of some abartieular manifestations allied to the rheumatic diathesis. There is now in : >man, 1 See Colombel : Recherches sur l'Arthrite Seche. Th: b m>3. 8 Op. cit. Obs. xvii., pp. 44 and 301. THE DISEASES OF OLD AGE. 145 forty-six years old, who, after first having a dry arthritis of the hip-joint, was later on attacked by a similar condition of the knees. Another patient, a woman, sixty- three years old, first had dry arthritis of the right hip-joint, next of the left, and then a painful swelling of the left knee with crepita- tion ; finally the nodosities of Heberden made their appearance. D. — Lastly, quite a number of cases are met with where rheumatism, after having been stationary for a longer or shorter time upon a certain number of joints, becomes general. Two opposite transformations may be met with : at times partial rheumatism becomes general ; and again, on the other hand, a single articular affection is observed to predominate in a case of general rheumatism, and the affected joint finally develops the lesions of arthritis deformans. Several examples of this are recorded by Adams. Among others, he quotes the case of Dr. Percival, a very distinguished physician, who died in 1839, at the age of eighty-two, after having long suffered from this disease. In 1818 he had quite severe pains in the hands and wrists, accompanied by slight swelling. Tsvo years later there was a little pain in the right coxo-femoral articulation, and gradually walking became extremely difficult to him. The limb was shortened and rotated externally ; its movement was accompanied by well-marked crackling ; and, when at rest, the limbs were crossed ; he could not move from this atti- tude without inducing pain. Five years before he died analogous symp- toms occurred in the left hip-joint. Dr. Percival's death was caused by a disease of the bladder ; and, in conformity with his last wishes, an autopsy was made by Dr. Colles, and the specimens were presented to the Pathological Society of Dublin. The articulations presented the most characteristic type of senile arthrocace ; * the heads of the bones were flattened and eburnated, as were also both acetabuia. The ligamentum teres had completely disappeared. The neck of the femur was shortened ; the head of the left femur was reddened and vascularized, numerous bony deposits covering the capsular ligament. In the case of a woman of sixty, who had suffered from nodular rheu- matism for twenty- five years, the disease finally became localized in the knees, which were ankylosed at right angles, and presented all the typical symptoms of a dry arthritis. But, in whatever way partial rheumatism originates, it is rather an in- firmity than a disease when once it has attained the chronic stage. I make an exception here of the visceral lesions that may follow in its train. We must not forget, however, that acute exacerbations occasionally occur. The articular affection that has so long been painless, finally gives rise to intense sufferings, the skin reddens, and we mark an evident aggravation of the chronic symptoms. The purely articular phenomena, when the disease is regularly estab- lished, are the following : First. — There is more or less pronounced deformity of the joint ; os- seous ridges or crests, foreign bodies, and hydrarthrosis, are present. Second. — The patient suffers spontaneous pains, quite vague in charac- ter, which pass off as he walks, but which finally become excruciating as the malady progresses. Tliird. — No pain — or almost none — is produced by palpation or percus- sion — a peculiarity which distinguishes this arthropathy from those of a serious nature. 1 Arthrocace —ulcer of bone ; (?) osteo-sarcoma. — L. H. H. 10 146 CLINICAL LECTURES ON Fourth. — There is always more or less well-marked crackling or crepi- tation. This disease, when exempt from all complication, in no wise threatens life ; but it does away, more or less completely, with the movements of the parts affected. Nevertheless, the patients frequently continue to walk, though not without some difficulty. It is in these cases that the autopsy reveals striations upon the eburnated portions of the cuticular surfaces of the bones of the joint. Spasmodic retraction of the muscles is very rare here, save at the com- mencement, but occasionally the ligaments are extremely relaxed ; or, again, as we so often observe in the hip, there is very great rigidity of the articulation, on account of the deformity of the heads of the bones, or of their receptive cavities. Nodosities of Heberden. — We now purpose to consider 11 ities, a special form of chronic rheumatism that has not yet been sufficiently described, and which, indeed, writers scarcely mention. Must physicians confound it with gout, without reserve or restriction. We readily see that nodular rheumatism differs from true gout in many characteristics ; but, in the case of Heberden'fl nodes, we are told that to doubt any longer would be unreasonable — the disease certainly is gout. Personally, I hold the contrary opinion ; and I designate this form of rheumatism by the name of nodositi>'* of Heberden, because this author was the first to recognize that these lesions ought to be separated from those of gout. "What," he says, in his " Commentaries," "what is the nature of the small, hard nodules, about the size of a pea. that we so frequently meet with in the fingers, especially upon their extremities, near the joint? Tkey have no connection with gout." These little nodosities, as Heberden observes, have their seat at the articulation of the terminal phalanges. The digital extremity is in general but slightly deviated either to the right or left. There are two nodules on a level with the joint, which seems, besides, a little enlarged. There is rigidity, but no crackling or crepitation, in the diseased articulation. In the majority of cases the advent of this condition is vary obscure ; but during attacks, or "fits," we have pain, heat, and temporary swelling of the soft parts. These are genuine attacks, which the patients often re- gard as gouty. The minute anatomical lesions of this arthropathy have n< been described. According to the numerous investigations which I had the opportunity of making at the Salpetriere, we find the changes of a dry arthritis here, as in the case of the two other forms of chronic articular rheumatism ; I have ascertained this fact myself in many dissections. The articular cartilages undergo the "velvety" change; then they disappear, and we find in their place a layer of eburnated bony tissue. The articular sur- faces are enlarged in all directions, on account of the formation of phytes which, while enlarging them, almost reproduce their normal form and contour. The pisiform tumors that, according to Heberden's descrip- tion, are met with in the vicinity of the second phalangeal articulation, are nothing but osseous tubercles, which are normally present at the lower extremity of the dorsal aspect of the second phalanx : but there is a con- siderable increase in the volume of these tubercles from the apposition of new osseous layers. There is not a trace of urate of soda, either in the THE DISEASES OF OLD AGE. 147 deeper portions of the articular cartilages, or in the soft parts in the vicin- ity of the joints. The remaining joints of the hand are usually affected, although to a much less extent. Contrarily to what occurs in nodular rheumatism, the lesions are best exhibited upon the articulations of the proximal with the second phalanges, and secondly, on the line of the metacarpophalangeal articulations. These nodosities are interesting to us, since they reveal a constitutional condition, which is neither more nor less than the rheumatic diathesis. This disease, of very frequent occurrence in the Salpetriere, belongs especially to the senile period of life ; but it must not be thought that it is never met with in young subjects ; quite the contrary, we often observe it at far less advanced years, and this is an important point to demonstrate. Here is an hereditary disease ; it may manifest itself in several members of the same family. It has palpable relations either with nodular, or espe- cially with partial rheumatism ; indeed, it is frequently seen to accompany arthritis of the hip or knee. It sometimes happens that, in the same family, some have Heberden's rheumatism, others general chronic rheumatism, and still others partial rheumatism ; another proof of the bond uniting these three forms of one and the same disease. Heberden's rheumatism is often coincident with asthma, megrim, neu- ralgia? — especially sciatic neuralgia, and muscular rheumatism. These manifestations may likewise alternate with acute attacks of this disease. It is not rare to meet with it in individuals suffering from cancer of the breast or of any other organ. Lastly, these nodosities may occur in gouty subjects, as I had the opportunity of noticing quite recently. But in the case in question they preceded gout by several years. 148 CLINICAL LECTURES OX LECTURE XVII. ETIOLOGY OF ARTICULAR RHEUMATISM. Summary. — The Principal Causes of Articular Rheumatism — Are Common to all the Forms of this Disease — Historical Pathology — Preponderance of Gout in the Writings of Physicians of Antiquity — Xodular Rheumatism, however. Already Recognized — Medical Geography — Acute Articular Rheumatism, a Disease beloDg- ing Especially to Temperate Climes — Unknown Around the Polar and Equatorial Regions— Chronic Articular Rheumatism Abounds in Temperate Climates, but likewise Occurs in Hot Countries — Heredity : its Incontestable Influence- tistics taken from Various Authors — Age — The Classical Period for Acute Rheu- matism between Fifteen and Thirty Years — Chronic Rheumatism Especially met with at Two Periods of Life : from Twenty to Thirty, and from J - \ty — Sex — Men more Liable to Acute Articular Rheumatism — Women to Nodular Rheumatism. External Causes — Wet Cold — Damp Habitations— Poverty. Insufficient Alimen- tation — Traumatic Causes — Blows. Fall>, Phlegmon, Whitlow — Pathological Causes — Erysipelas — Angina — Scarlatina — Blennorrhagia (Gonorrh Uterine Functions— Chlorosis — Dysmenorrhoea — Menopause — Pregnancy — Pro- longed Lactation. Comparison between the Etiology of Rheumatism and that of Gout — These Two Diseases not Identical, but a certain Degree of Relationship Exists between Them. Gentlemen : — The study of the causes which preside over the develop- ment of articular rheumatism furnishes new proof in support of the theory we have constantly upheld. Indeed, upon the ground of etiology, we shall see the various forms of this disease approximate and become intermingled ; we shall see them, on the other hand, diverge farther and farther from gout. And thus we shall establish the fact that the types apparently so different, which we have de- scribed heretofore, acknowledge essentially a common origin. It must not be overlooked, however, that, according to a few observa- tions, articular rheumatism has induced a predisposition to gout thi the influence of heredity ; and the converse of this seems, ako, to be none the less certain. I. — Historical pathology and medical geography. — While we were studying the history of gout, we stated that articular rheumatism had received but very little attention on the part of the physicians of antiquity, who- scriptions are almost wholly confined to gout : that they likv found the latter disease with rheumatism under the name of the articul (articulorum passio). Baillou is the first writer who g scription of rheumatism ; and the proof that this distinction requi time to become established is to be found in the fact that it was not yet admitted in the first editions of Boerhaave. The silence of the physicians of antiquity ha imagine that rheumatism did not appear before modern tinn - found in the ruins of Pompeii afford us more positive information on this THE DISEASES OF OLD AGE. 149 point than medical literature can furnish, at least so far as chronic rheuma- tism is concerned, since in many instances the characteristic lesions of this disease were actually found among the human remains. Most valuable and important information on this subject can be found in the " Osteologia Poinpeiana," by Professor Delle-Chiaje of Naples. The plates accompanying the text banish every doubt from the mind of the reader. A medical geography has yet to be written. Under the influence of cer- tain preconceived ideas a deplorable confusion has arisen among all the diseases which trace their origin to cold ; and it is easily understood how difficult becomes the task of criticism when observations made in remote regions are to be examined and tested. It seems to be established, however, that acute articular rheumatism is a disease that abides more especially in temperate climates : it is unknown in the immediate vicinity of the poles and the equator. But this disease is quite frequently met with in hot countries : it often occurs in Egypt, ac- cording to Pruner-Bey, and in the East Indies, according to Webb ; in the latter country it is frequently complicated by an endo-pericarditis. At the Cape of Good Hope, the geranium's native home, the number of cases of rheumatism in one thousand sick in the English army, was^?/b/- seven ; while in the rigorous climate of Nova Scotia there were only twenty suffering from rheumatism in the same number of patients. Concerning chronic articular rheumatism, we possess no positive infor- mation, although it is at least certain that it prevails in temperate climes : in England, Ireland, France, Germany, and all Central Europe. But it may also occur in hot countries. In India, Malcolmson has found it among the Sepoys ; and I myself have observed that it is a frequent disease in Naples. II. — Heredity. — The study of this question possesses the greatest im- portance for the theory of rheumatism, since hereditary diseases are not accidental and transient, — they are in the very constitution of the patient ; this is well seen in the case of gout. The statistics of Chomel and Kequin here establish the frequency of hereditary transmission ; unfortunately, however, these authors confounded gout with rheumatism. But Fuller, who holds to the distinction between them, found the hereditary transmission of rheumatism 96 times in 300 cases, or a proportion of 29 per cent.; 1 while for gout the proportion is 50 per cent. New investigations are indispensable in the case of chronic articular rheumatism. Still, all we do know of it tends to establish the fact that this disease often proceeds, because of an hereditary tendency, either from acute rheumatism, or directly from chronic rheumatism. There can be no doubt upon this subject as regards vodular rheuma- tism. In forty-five cases of this type, Trastour states that the father and mother were rheumatic ten times, and three of the female patients had children who were already attacked with articular rheumatism. I observed an interesting case of this kind myself. There is now in the Salpetriere a woman that has nodular rheumatism, whose daughter and grand-daughter are already suffering pains in the smaller joints. Here are three generations successively attacked with the same disease. 1 Prof. Charcot says : "96 fois sur 300, ce qui dorme une proportion de 29 pour 100." It should read " 87 times in 300 cases." See Reynolds : A System of Medicine. Vol. i., p. 938.— L. H. H. 150 CLINICAL LECTURES ON In Heberden's rheumatism, heredity seems established according to per- sonal observations of my own ; this is very frequently a family disease, a point to which Garrod has already drawn attention. Concerning partial chronic rheumatism, the question is still under inves- tigation, and I will not venture an opinion thereon. HE. — Age. — The classical time for acute articular rheumatism is between the ages of fifteen and thirty, although this disease is not rare in the ear- lier years of life; it develops in children of five and ten, and, according to West and the majority of writers, heart disease is more frequent in young people than in older subjects attacked with this form of rheuma- tism. And here is a difference to be pointed out between this disease and gout, inasmuch as the latter is rarely developed before the twentieth year, as we have already stated (p. 87). The acute form of articular rheumatism seldom occurs after the age of fifty. In one hundred and ninety-nine cases, Macleod saw it develoj) only once after fifty-five years of age ; and Fuller, out of two hundred and eighty-nine cases, observed only seven after fifty years of age. I have seen two cases of this kind occurring after seventy years. The first case was a slight acute rheumatism, and the second was subacute febrile rheumatism of a very obstinate nature. For nodular rheumatism, Trastour and myself have proved that there are two periods of life when one is more particularly liable to suffer an attack; it is from twenty to thirty, the epoch of complete development, and from forty to sixty, the time of the menopause, that this disease preferably ap- pears. Thus Haygarth was wrong in ascribing chronic rheumatism almost exclusively to the menopause. Nevertheless, this disease may manifest itself either before or after the periods we have named. We have many observations that are sufficient proof on this point. Thus, Laborde brought before the Society de Biologie a little boy. eight years old, who had all the characteristic deformities of nodular rheumatism; the disease commenced when he was four years of age. I have already de- scribed, when speaking of rheumatic pericarditis (p. 180), the remarkable case that Martel recorded in the service of Dr. Barthez. I have myself observed the following cases : A patient in the Salpetriere, who had been reared in a damp dwelling, and who was attacked with nodular rheumatism at the age of ten. Another in the same hospital, who had lived since her infancy in a damp lodge, was attacked when sixteen years old. Finally, a man brought up in one of those deserted quarries on the banks of the Loire, that so often serve as dwellings, was attacked with nodular rheumatism at the age of twenty, Partial rheumatism is — especially arthritis deformans — chiefly met with in individuals more advanced in life ; they frequently occur in middh people. Only in the young are these diseases exceptional. Yet cases have been seen under thirty years of age. As for Heberden's nodosities, we have seen that they may occur in young subjects, notwithstanding they especially belong to the senile period*. IV. — Sex. — Men are oftener attacked with acute articular rheum.: than women. But there is no well-marked difference in this Nodular rheumatism is incomparably more frequent in females |Trastour, THE DISEASES OF OLD AGE. 151 Vidal) ; a convincing proof of this is afforded by a comparison between the inmates of Bicetre ' and the women in the wards of the Salpetriere. Partial rheumatism is perhaps more frequent in men; this is especially true for arthritis deformans. Heberden's nodosities seem to be more frequent in the female sex ; but this point is still an unsettled one. External causes. — First : Wet cold. — A sudden and transient impression of cold can only be considered as an occasional, and in no wise as a specific cause of rheumatism. Eisenmann's mistake must be avoided: he wrote a work, " Erkaltungskrankheiten " (diseases from cold), in which rheumatism comprises the whole pathology, or very nearly the whole. It is nevertheless certain that, in predisposed individuals, cold has a powerful tendency to evolve either acute articular rheumatism, or chronic rheumatism of a rapid development. But we are far from calling in question the influence of a prolonged resi- dence in a damp dwelling. On the contrary, we here recognize the most efficacious cause of both acute articular, and of nodular rheumatism in par- ticular. About three-fourths of the women attacked with the latter disease ascribe it to the prolonged influence of damp cold. When stating this to be an invariable condition, Beau has undoubtedly exaggerated an unques- tionable truth ; but certainly this cause is present in the majority of cases. A dwelling on the ground floor, damp, dark rooms, wet garments, the paper peeling from the walls — this is the condition in which we find the homes of most of those who are attacked with chronic rheumatism ; and besides, the patients have lived a long time in these sorry surroundings — for four, six, eight, and even ten years. In the vicinity of Chantilly there are genu- ine troglodytic dwellings ; they are underground excavations in the interior of deserted quarries. Among the unfortunates who take refuge there, a large number, according to Beau, become subjects of nodular rheumatism. We need not wonder at this ; but it must not be forgotten that, in many coun- tries, people still live in subterranean abodes without appearing to experience any great inconvenience therefrom. This is the case, for example, in certain provinces in the Russian Empire, notably Georgia. During the "retreat of the ten thousand," you know that the Greeks, when they reached Arme- nia, found the inhabitants of that country lodged in excavations of this kind, and that in the middle of the coldest winter they were most comfortable in these well- warmed abodes. 2 Recollect, besides, that these are cold coun- tries, and they only bury themselves underground to escape the severity of the climate. Now, we have seen that excessive cold is not at all favor- able, in general, to the development of rheumatism. But, in temperate regions, it is more difficult to escape it when such conditions of life are present. Yet the disease does not usually break forth without premonition ; there is oftenest a period of incubation during which patients merely experience vague muscular pains. Articular manifestations frequently do not develop until three or four years after the cause has ceased to exist. Second. — The influence of poverty and insufficient or improper food, upon the development of rheumatism, cannot be called in question : the in- 1 Bicetre : asylum for old people and lunatics, in the neighborhood of Paris. — L. H. H. 8 Xenophon: "Avafiaaig. Book iv., § 48. 152 CLINICAL LECTURES OX digent in the English and Irish workhouses offer numerous instances of nodular rheumatism, proving certainly that the disease is an especially ple- beian malady, notwithstanding Hay garth's opinion to the contrary. Third. — Traumatic causes, as in case of gout, may determine both the outbursts and the primary location of the disease. We possess several observations where acute or chronic rheumatism has developed after a blow, fall, phlegmon, or whitlow, appearing first at the articulation nearest the injured part. In a woman attacked with nodular rheumatism, the disease commenced in the right shoulder, which had previously received a severe contu- sion. A batcher, already rheumatic, developed a phlegmon on the hand from a punctured wound of that member ; an attack of acute rheumatism com- menced in the wrist-joint, about the spot which was the principal seat of the phlegmonous inflammation. A whitlow upon one of the fingers of a woman in the Salpctric-re marked the commencement of a nodular rheumatism in the joints nearest to the diseased part. Partial rheumatism frequently develops after a fall or a blow ; and it is here difficult to determine whether it is a general disease, or a purely local affection secondary to the external violei. VI. — Pathological causes.— These often act in the same manner as exter- nal accidents. Acute articular rheumatism develops subsequently to a large number of different diseases. In an individual who was already rheumatic, a facial erysipelas, con- tracted during an epidemic of this disease, was the starting-point for acute articular rheumatism. This case must be distinguished from those where erysipelas is a part of the manifestations of the rheumatic diathesis ; for I could cite several instances of nodular rheumatism where the attacks of erysipelas have alternated with the articular symptoms. A few facts tend to establish the existence of a rheumatic angina ; but it is quite certain that a purely accidental angina has many a time be. starting-point of an attack of acute articular rheumatism. The connection between articular affections and scarlatina is well known. Two kinds of cases must be distinguished in thi S< »metime- let fever induces the outburst of an articular disease in no way distinguish- able from acute rheumatism ; and again, on the other hand, it is an ar- thritis clearly of an opposite nature, benign in the vast majority of according to a remark of Trousseau's, but which may become very and assume a purulent character, as Garrod hasobeervt d. The I alone deserve the name of scarlatinal arthritis ; the former belong to acute articular rheumatism, scarlet fever having here only played the part of a provocative. It is the same with blennorrhagia. Is there a blennorrhagic (gonorrhoeal) rheumatism ? Here is a question that deserves our attention for a few moments. In the majority of cases where articular symptoms are produced in con- sequence of an urethral disease, subacute arthropathies, to the nun.; two or three, are seen to appear in company with an iritis (BoUet) ; this is the classical type of blennorrhagic arthritis (gonorrhoea! rheumatism I But acute articular rheumatism with an endocarditis may also lx? ob- served to supervene upon a simple clap. A case of this kind was by Brandes, and Professor Lorain communicated a second to m Finally, chronic rheumatism attended by deformity of the joints, may THE DISEASES OF OLD AGE. 153 also be occasioned by this disease (Garrod, Lorain, Broadhurst, Trous- seau). ! How can we interpret these facts? Are the manifestations in these cases always rheumatic ? Undoubtedly they are not. We know that the arthropathies which follow fevers are not always associated with this diathe- sis. The articular manifestations in glanders, small-pox and purulent in- fection (pyaemia) are clearly non-rheumatic in character. It may be, then, that there is a scarlatinal or blennorrhagic (gonorrhoea!) arthritis inde- pendent of rheumatism. I am even convinced that this is frequently the case ; but the articular disease that arises in such circumstances is often an undoubted rheumatism, developed secondarily to those affections which also, in certain instances, possess the inherent power of attacking the joints. 2 VII. — The uterine functions. — All authors recognize the influence ex- erted upon the development of the various forms of rheumatism by the functions of the female genital apparatus. And this is true not only for the acute form, but also for the chronic variety of the disease. Indeed, the appearance of the ' catamenia, the menopause, pregnancy, delivery, the puerperal state, and lactation, are causes which in women ex- ert a powerful influence over the development of articular rheumatism. And concerning this, let us enter somewhat into details. Chlorosis is a base on which the articular manifestations of rheumatism are very apt to develop. Musgrave cites several cases of arthritis ex chlorosi that evidently belong to nodular rheumatism. The happy results arising from the administration of iron are aflirmed in many cases of this kind. It is well known that the menopause is frequently accompanied by a con- dition analogous to that of chlorosis in young girls, and it is likewise a settled fact that chronic rheumatism often develops at this period of life. Pseudo-membranous dysmenorrhoea has been described by Todd among the diseases that accompany nodular rheumatism. It is perhaps not un- interesting to observe in this connection that dysmenorrhoea frequently accompanies the eruptions (erythema nodosum, for example) that are oc- casionally met with in acute and subacute rheumatism. In individuals already suffering from the malady, each menstruation has produced an exacerbation of the pain. The abrupt suppression of the menses, follow- ing upon some intense emotion, has occasionally been the starting-point for nodular rheumatism. Pregnancy is likewise one of the causes of this disease. In a work which my colleague, Dr. Lorain, was kind enough to send me, are recorded several examples where acute, or subacute articular rheumatism, has ap- peared in women who were with child. In my thesis I have reported sev- eral cases of nodular rheumatism which developed under the same condi- tions ; Todd had already noted the same coincidence. It is not rare to see an isolated arthritis appear during pregnancy, and become general after delivery. Besides, acute rheumatism itself has been seen to occur during pregnancy (Chomel and Requin, Todd). It must not be forgotten, however, that multiple purulent arthropathies may be de- 1 Garrod on Gout, p. 545. Broadhurst iu Reynolds' System of Medicine. Vol. i. , p. 920. Trousseau: Clin. Med. de l'Hotel-Dieu. Vol. iii., p. 375. Professor Lorain's case was a verbal communication. 2 See a discussion on this subject, occurring in the Medical Society of the Hospi- tals : Union M dicale, December 23, 1866, and March 5, 1867. 154 CLINICAL LECTUEES ON veloped in confinement. "We think that these cases have been wrongly- designated by the name puerperal rheumatism. Another condition in which the various forms of rheumatism — sub- acute and chronic especially — may present themselves, is lactation, particu- larly when this is long-continued (Lorain, Garrod). 1 It would be interesting to compare this etiology with that of gout, and exhibit the differences between the two ; but time presses, and we must content ourselves with a general view of the question. Generally speaking, it is true that the causes of gout are associated with comfort, excesses, and good cheer ; in the same general way, rheuma- tism, especially the chronic form, has poverty, damp cold, insufficient food, and debilitating influences of various kinds, as its etiological factors. But the contrast becomes } r et more striking if we compare the diseases usually associated with gout, with those habitually accompanying rheuma- tism. On the one hand we find diabetes, 2 obesity, and gravel, 3 whose rela- tionship with gout we have already proved (pp. 75 to 79), and whose ap- pearance in rheumatism is rarely obseiwed ; on the other hand, scrofula,* phthisis, and cancerous affections, 6 of frequent occurrence in chronic rheu- matism, are very uncommon in gout. Here, certainly, are differences between the two diatheses from an etio- logical standpoint ; and yet, in spite of these great diversities which sepa- rate them, and which we have endeavored to make clear and prominent, they still offer remarkable analogies ; indeed, they have frequently been con- founded. And even when they have been differentiated, they must neverthe- less be approximated in every good nosological classification. It is certain, moreover, that a relation capable of being demonstr in many ways, closely associates rheumatism and gout. They sometimes appear- in the same individual, who presents at the same time the lesions of both gout and chronic articular rheumatism. Again, acute articular rheumatism cccurs in a patient during his youth, and then gout is developed at the usual time therefor. 8 1 On Gout, p. 5G8. 2 In two hundred and twenty-five cases of diabetes. Griesinger, in his Studies of Diabetes, only twice found acute articular rheumatism. I do not think that diabetes has ever been observed as a complication of chronic rheumatism. 3 1 have seen uric acid gravel occurring in a woman with nodular rheumatism ; but an examination of the blood at several different times, in this case, never revealed an excess of uric acid therein. 4 Scrofula very frequently appears among the antecedents qf individuals attacked with progressive chronic rheumatism. It is very common to see those patient- specific cicatrices of the neck. I could mention several cases where wonun who, during their youth, have had white swellings, and in whom, at a later period, nodu- lar rheumatism has developed. In one hundred and nineteen cases of nodular rheu- matism, Fuller (loc. cit, p. 334) states that twenty-three {ox one -fifth of the whole) had mother, father, or collateral relations presenting evident signs of phthisis pulmo- nale. This disease, I can avow, often carries off patients afflicted with nodular rheu- matism ; and in such cases it seems to me that the phthisis was remarkable for its slow development. In individuals attacked with acute rheumatism, phthisis is rare (Wunderlich, Hamernjk). Still, a coincidence of these two diseases Dan- joy, who has directed attention to this point, thinks that the disease is then modified in its development — that it is retarded. 6 1 have often convinced myself, in the Salpetriere, that the coincidence of Heber- den's nodosities either with cancer of the breast or cancer of the uterus, is not an ex- ceptional circumstance. 6 See Baillou on this subject, vol. iv., p. 415. Was it this that made Junek.r rheumatkmus arthritidem online u/ttecedit? THE DISEASES OF OLD AGE. 155 Finally, a relationship may be established between them by means of heredity. Acute articular rheumatism occurs frequently in the children of the gouty (Heberden, Fuller, Todd). The children of the rheumatic often become subjects of the gout (Fuller). Indeed, heredity may show itself in the collateral branches : I have myself seen nodular rheumatism appear in a woman whose brother was gouty. Do these relations, apparently so close, prove the identity of these two diseases ? No, certainly not : at the utmost, let us admit the existence of a common foundation, a common basis, an articular predisposition, an arthritic condition, whence both affections take their origin. 156 CLINICAL LECTURES ON LECTURE XVIII. TREATMENT OF GOUT AND CHRONIC ARTICULAR RHEUMATISM. Summary. — General Considerations Concerning the Treatment of Gout— Treatment of the Attacks or Paroxysms — The Expectant Plan — Quack rtemedies- -Colchicum — Advantages and Disadvantages of this Agent — Rules which should Govern its Em- ployment — Narcotics : Hyoscyamus and Opium — Sulphate of Quinia — Iodide of Potassium — Tincture of Guaiacum — Topical Remedies — Leeches- M. xa — Treatment of the Constitutional Condition — Alkalies — Their Various Properties — Sodium. Potassium, Lithium — Action of these Drugs '.Ikaies are Contraindicated — Mineral Waters — Tonics and Stomachics — Treatment of the Local Affection : Chalk-Stones and Rigidity of Joints — Treatment of Abnormal Gout — Dietetic Regimen. Treatment of Chronic Articular Rheumatism — Unsatisfactory State of our Knowledge upon this Subject — Treatment of the Act. .—Opium, Sulphate of Quinia, Bloodletting — Alkalies — Tincture of Iodine — Arsenic Inter- nally and Externally — Tincture of Guaiacum— Iodide of Potassium — Iron, Cod- Liver Oil — Blisters, Revulsives — Mineral Waters— Medical Art Powerless in the Majority of Cases. Gentlemen : — "We reach, to-day, the last part of our course. We have postponed the treatment of gout until the close of our lectui - to be able to compare it with that of chronic articular rheumatism. And this question we shall now discuss. Treatment of Gout. I. — General considerations. — Gout is a constitutional, hereditary dis- ease, and primarily chronic, notwithstanding its acute manifestations. But gout is also at times an acquired affection, now arising because of errors in diet, and now from other causes ; this is a kind of spontaneous generation. It may be concluded that hygienic influences are here placed in the first rank, and that therapeutical agents only occupy second place. Indeed, ex- perience has long since demonstrated the truth of this statement We do not mean to say that the disease is radically incurable : exam- ples of spontaneous cure are on record, but our art has not yel been able to reproduce with certaiuty the processes of nature. The proper means do exist, however, for lessening the effects of the dis- ease, and to avert its paroxysms ; upon these, collectively, rests our I ment of the constitutional condition during the interval between the at- tacks or fits. But we have a humbler, although more useful mission to fulfil. The periodical manifestations — the paroxysms— of both acute and chronic gout, are accompanied by terrible and often unbearable suffering. Can we suppress these crises of pain, or at least diminish their iute: THE DISEASES OF OLD AGE. 15? and shorten their duration ? This constitutes the treatment of a paroxysm of gout. Let us first consider the latter point. II. — Treatment of a paroxysm of acute or chronic gout. — This is a ques- tion of treatment which is in great measure palliative in character. A few physicians have even gone so far as to proscribe all means of relief as dan- gerous and pernicious. This is Sydenham's school, which assumes the tel- eological standpoint ; this great teacher says : " Dolor acerrimum naturce pharmacum." " Gout is gout's best remedy," said Mead ; and Cullen pre- scribed "patience and flannel." The partisans of the expectant plan base their belief on the inefficacy of known remedies, on the danger of their application, and especially on the relief experienced by the patient after the attack or fit. But to these argu- ments it may be answered that the inertness of capable men opens the way to quacks. The physician leaves a gouty patient — the quack seizes upon him. They appear with remedies which give almost instantaneous relief, and, if they sometimes induce grave symptoms, are yet often free from all real danger. Such are Keynold's elixir, Lavihe's anti-gout liquid, Audu- ran's wine, Lartigue's pills, etc., etc. Now, I believe it is well established that all these so-called specifics owe most of their efficacy to the presence of colchicum. And thus it is the part of the physician to attentively study the therapeutic properties of this formid- able agent, which sometimes affords the patient the greatest relief without any harm, and again induces serious symptoms that may end in death. No one, indeed — not even its bitterest enemy, denies its potency. It causes the gouty inflammation and the terrible pain that accompanies it to disappear as if by magic. In this respect its action is nearly similar to that of quinine in intermit- tent fevers ; and here, again, is one of the differential points between gout and articular rheumatism. In the acute form of the latter disease, Professor Monneret has already shown that colchicum is useless ; and in the different forms of chronic rheumatism, I have assured myself that this drug possesses no advantages whatever. How does it act in cases of gout ? Since the sixth century of the Chris- tian era, the ancients were acquainted with the advantages and disadvan- tages of colchicum. Alexander of Tralles tells us that, in his time, it was given only to those who were busy with their work and had no time to be sick. Demetrius Pepagomnenus, who lived about the year 1200, calls it Theriaca artieulorum. But the colchicum of the ancients is not our colchicum. They used the hermodactyl l (colchicum variegatum, Planchon); to-day we use the colchicum autumnale. Fallen into neglect, this drug was again brought into notice and use by the effects of Husson's remedy. Everard Home extolled colchicum, which Storch had already brought into vogue for other diseases than gout. Later on its effects were carefully studied by Wandt, Halford, Watson, and" Garrod. All parts of the plant are used — bulb, seeds, and flowers. It is admin- istered as the extract, wine, or tincture. The wine of colchicum-bulbs is administered in doses of from two to six grammes, twice or four times dur- ing the twenty-four hours (thirty minims to a fluid drachm and a half); the 1 Hermodactyl: Mercury finger. — L. H. H. 158 CLINICAL LECTURES ON acetic extract is prescribed in doses varying from five to fifteen centi- grammes (gr. j.-ij., nearly). A word concerning the physiological effects of this drug. In large doses it causes : First. — More or less serious gastro- enteric phenomena. Second. — A marked sedation or depression of the circulatory system, with a tendency toward algidity and slowing of the pulse. Third. — Finally, nervous symptoms and a peculiar kind of drunkenness. In small doses it merely creates slight nausea and a moderate retarda- tion of the circulation. Now, it is in small doses, at least when it is tolerated, that it acts favor- ably in gout ; in its administration we must avoid the inflammatory phe- nomena on the part of the digestive tract ; indeed, its action seems to be the more efficacious the less pronounced are its operative effects {effete visibles). Its specific action is shown in the disappearance of the gouty inflamma- tion and the pain that accompanies it ; resolution occurs, as if by magic, at the end of eight to fourteen hours. It is far from possessing the same degree of influence over other inflammations and the various forms of ar- ticular rheumatism, as we have previously intimated. What is its mode of action ? This is a question which has not yet been solved. No effects have been attributed to the elimination of uric acid ; this theory, upheld by Chelius, Maclagen, and Gregory, is combated by Garrod, Bocker, and Hammond. The latter base their opinion upon care- ful urinary analyses that seem to leave no opening for criticism. Its sedative action upon the circulation has been adduced as a reason ; but this is certainly not the secret, since it does not act in the same way in other inflammations. Its purgative action is also out of the question, for its specific proper- ties can manifest themselves without the occurrence of any intestinal evacuation. We cannot, finally, ascribe it to its narcotic power, for even in this it presents an effect peculiar to gout. Be this as it may, its efficacy is beyond all question. But we must look upon the dark side of the picture, and see what dangers the administration of colchicum involves. It is beyond dispute that, when imprudently given, very serious results may be the consequence. What are the rules, then, that should govern its administration? First. — Gout is a retrocedent disease, as we have previously proved. If, then, you abruptly suppress an attack or paroxysm, visceral derange- ments may be developed ; but no such danger is to be dreaded when small doses are exhibited. Besides, colchicum ought not to be administered immediately upon the outbreak of the attack (Halford, Troon days should elapse before beginning its use. Finallv, we should fear its irritating action upon the digestive tract ; and this is another reason for not prescribing large doses. Second, — Not only must we avoid the exhibition of large doses, but it is also necessary to suspend the drug for a time, since, in certain pa: its effects appeal* to be cumulative. Under such circumstances of of potassium, injected into the vein of a medium-sized enough to cause its death ; twenty centigrammes (a little over tlir> cient to kill a rabbit. To obtain the same results with a sodium salt, at least three times as strong a do» essarv. Let us now consider the special action of each of these substances taken separately, and, beginning with the two bases which are most commonly administered, let us institute a comparison between Hum. The salts of potassium possess a diuretic action : this fart has been thoroughly proved by Mischerlich. The salts of sodium do not | marked a diuretic action. The solvent action of potassa upon uric acid is much more energetic than that of soda. It is well known that the urate of potash is much more soluble than the urate of soda. Besides, when a cartilage inerusted with urate of soda is plunged into a solution of carbonate of ] u ob- serve a rapid, solvent.action ; if, on the other hand, it be placed in a solution of carbonate of soda, you scarcely obtain any appreciable effect in the same period of time. Thus, a priori, potassa is more efficacious than sod base is useful in those cases of gout where there is live: rding to Garrod. But there is a substance little known even at the present day. namely, lithium, which seems in every respect to prevail over potash and soda. This metal, discovered by Arfwedson in 181" in many min- 1 Berliner klin. YVochen. 1 965. 2 Previous to the publication of Garrod's tre.itise. Pr. Galtn r- attention to the much greater intensity of pota solving Mtii red to that of soda, in the treatment of gout. *De la Goutte. p. 112. ThtW de 1 THE DISEASES OF OLD AGE. 161 eral waters — in Carlsbad, Vals, Vichy, Baden-Baden, and Weilbach, in which latter town there is a newly discovered spring that is called " Natrolithion- quelle" (sodium-lithium spring), and contains a large proportion of this substance. Spectrum analysis enabled Bunsen and KirchofT to determine its pres- ence in human milk and blood. It is not, then, a substance foreign to our organism; and if potassa exists in the blood-corpuscles, and soda in the serum, lithium is likewise found, though in very minute quantity, in the nourishing fluid of the economy. This new agent answers all the indications we have enumerated. It has a well-marked diuretic action ; it makes the urine strongly alkaline, and dissolves uric acid energetically. In this respect it is much superior to potassa, for the urate of lithia is the most soluble of urates. Garrod performed the following experiment : into three solutions, the first containing five centigrammes of carbonate of lithia {four-fifths of a grain) ; the second, five centigrammes of carbonate of potassa ; and the third, five centigrammes of carbonate of soda, to thirty grammes (very nearly one ounce) of water, — into each of these were put pieces of the same cartilage impregnated ivith urate of soda ; at the end of forty-eight hours the lithium had completely dissolved it ; the potash had only slightly acted upon it ; and the soda had given an absolutely negative result. Urate of lithia is clearly, then, the most soluble of all the urates. "What is the mode of action of the alkalies ujDon the blood in gout? They have no power to lessen the formation of uric acid ; nor can they dis- solve it, as various observers have supposed, for it exists in the form of urate of soda. But in rendering the tissues alkaline, they may hinder the forma- tion of deposits ; besides, the carbonates of lithia and potassa can dissolve existing deposits, a result the carbonate of soda cannot effect. Beyond this their influence would be useless, were it not for the fact that they pos- sess at the same time a diuretic action. This is what theory says ; and now let lis question therapeutical ex- perimentation. The alkalies, especially potash and lithia, when administered in small, in very dilute doses — for the action of water is most efficacious, and particu- larly when exhibited for a long period of time — possess a remarkable ac- tion in cases of gout. They postpone the paroxysms, they sometimes dis- solve and diminish the depositions that have already formed, and give more mobility to the joints. Carbonate of lithia is administered in doses varying from twenty-five to thirty centigrammes (nearly gr. iijss — gr. ivss.) for the twenty-four hours. I have prescribed it myself in forty centigrammes doses (six-grain doses) without producing any unpleasant effects on the stomach. Strieker l has succeeded in causing tophaceous deposits in a woman to disappear, by giving her an artificial imitation of the Weilbach water, made according to the following formula : Water charged with carbonic acid § xvj. Bicarbonate of soda gr. iijss. Carbonate of lithia gr. jss. This quantity represents the dose to be taken each day. Schutzenberger has advised the use of water charged with protoxide of 1 Virchow's Archiv. Bd. xxxv. 11 162 CLINICAL LECTURES ON nitrogen (nitrons oxide, monoxide of nitrogen) containing a gramme fgr. xvss.) to the litre (2.1 pints). Prescribing the alkalies in this way, we may be enabled to have them tolerated for several months. No serious inconvenience arises when the limits are the doses we have just mentioned. It is also necessary to know the cases where the alkaline treatment is applicable. It is formally contraindicated : First. — In individuals who are advanced in years. Second. — In those whose kidneys, being more or less deranged, no longer have the power of elimination. Third. — In those with whom alkalies disagree on account of some pecu- liar idiosyncrasy. It is perhaps not ill-timed to state, in this connection, that the dangers of saturation of the blood with alkalies is much exaggerated, at le far as bicarbonate of soda is concerned. My own personal experience is con- trary to the general, accredited views in this regard. To individuals suf- fering with chronic rheumatism I have frequently given apparently enor- mous doses of bicarbonate of soda, from twenty to thirty grammes (a little over 3 vijss.) in twenty-four hours, and sometimes for several months at a time ; and in such cases I have never seen either profound anaemia, <;:- tion of the blood, or multiple hemorrhages, which might hare been antici- pated according to the generally received notions on this subject. But, with regard to potassa in large doses, I have not had the opportunity to directly study its effects, and I am completely ignorant of the results it may bring about. There remain a few words to be said about mineral waters in the treat- ment of gout ; this naturally complements the study to which we have just devoted our attention. Generally speaking, waters loaded with saline ingredients precipitate the attacks and induce the crisis that should be averted. Certainly this absolute contraindication, but it is a point that the physician ought always bear in mind, so as never to be taken unawares by the i ment he has prescribed. Mineral waters are, in general, contraindicated in patients suffering or- ganic lesions of heart or kidneys. Concerning alkaline springs (Vals, Vichy, Carlsbad. etcA they seem to possess advantages at the commencement of the disease in the r especially in those who have hepatic affections. But they have no power to dissolve the tophi, and they are of little benefit in chronic gout, al when there is no dyspepsia. Sulphur saline (Aix-la-Chapelle) or simple saline waters (Wiesbaden) are best in the torpid fomi in atonic cases. There are indifferent waters, to make use of an expression sanctioned by German usage, whose mineral constituents are in such fiery small j . tion (apeines chargies), that the real active principle is the water imbibed in large quantities. In this class we may place, from our standpoint at least, the waters of Wildbad, Toplitz, Gastein. Bath, Buxton, and ville. They are frequently very beneficial in chronic gout. 1 instances we have seen Contrexeville water administered in case of a long-standing gout with tophaceous deposits, and the result seemed most favorable. Finally, chalybeate waters (Pymiont, Schwalbach. Bj ful in cases where iron is indicated. We shall limit ourselves to this brief statement of the action of mil THE DISEASES OF OLD AGE. 163 waters in the treatment of gout. If we were to give a critical estimate of all that has been written upon the subject both by avowed partisans of the waters, and by their adversaries, we could readily fill a volume. It is enough to say, in a general way, that on both sides there has been much exaggeration. Let us discuss for a moment the tonics and stomachics. They possess an indirect action upon gout by modifying the condition of the stomach, by combating atony, and by reviving the strength. They are very useful in cases of asthenic gout. The decoction of common ash (Fraxinus excelsior) leaves has been used with much success ; it has been recommended by Pouget and Peyraud. It is prepared in the following way : Leaves of Fraxinus excelsior (common ash) § i. Water Oij. Boil for ten miuutes. Garrod has employed this infusion * with a certain degree of success. Cinchona has likewise been used with advantage along with gentian, which is one of the principal ingredients of Portland powders. IV. — Treatment of the local disease, of tophi (chalk-stones), and rigidity of joints. — We should prescribe exercise for those suffering with gout, as it tends to diminish the rigidity ; this Sydenham has already demonstrated. To dissolve the tophi, it has been advised to make lotions of potash and lithia ; and when the concretions are of small size and superficially seated, the skin may be punctured in order to extract them, especially when they are semifluid. But generally, when they are large, hard, and deep-seated, all operative interference is forbidden, since it frequently happens that ul- cers result whose cicatrization is very difficult. Besides, it must not be for- gotten that we may have a dangerous erysipelas resulting from the slightest wound in gouty patients who are attacked with kidney disease, and espe- cially in diabetic individuals. When ulcers form spontaneously, the rule is to avoid intermeddling. V. — Treatment of anomalous gout. — It is a generally accepted and recog- nized fact that when gout has retroceded, especially to the stomach, we must have recourse to revulsives upon the articulations. Without question- ing their utility, let me observe that there are very few authentic records sufficient to establish the efficiency of this mode of treatment in bringing back a gouty inflammation to the joints. Stimulants, cordials, and brandy are often, on the other hand, followed by readily appreciable results, and experience seems to have demonstrated their utility. When it is a case of misplaced gout (megrim, ophthalmia, etc.) colchi- cum, administered in small doses, is indicated, according to Watson, Hol- land, and some other authors. But this is a question that, to us, seems far from being settled. VI. — Dietetic regimen. — A gouty individual should take plenty of exer- cise : he should let his diet be a sober one, but in no way exaggerated, for 1 Tanner states that the " dose is a tumblerful of a weak infusion of F. excelsior (one ounce of the leaves infused into a pint and a half of water), taken on an empty stomach, night and morning." — L. H. H. m 164 . CLINICAL LECTURES ON otherwise the development of atonic gout would be favored. Strong beer and wines rich in alcohol must be rigorously interdicted, but he may drink light beer, moselle, and claret. He should travel ; change of climate is fre- quently beneficial, according to the English physicians, who recommend India, Egypt, Malta, and other localities in the hot countries ; but such a change does not at all dispense with the observance of a proper regimen. Finally, mental hygiene must be regulated : the irritation so natural to this class of patients must be combated ; sadness, despondency, and the preoccuj)ation and excess of intellectual labor, must be avoided. Treat:\ien t t of Cheonic Articular Rheumatism. We have heretofore entered into so many details, that the latter part of this lecture must necessarily be abridged. It may be said that the treat- ment of chronic articular rheumatism is even less efficacious than that of gout ; we are still less advanced in this respect, arid we have not even colchicum with which to combat the most } mptoms of the disease. In cases where acute phenomena supervene, the indications are almost the same as in acute articular rheumatism. Opium, sulphate of quinine, local bloodlettings, etc., are sometimes prescribed with successful results ; but, in the great majority of cases, we are powerless to check the progres- sive course of the malady. Large doses of alkalies, according to Garrod, are here much less pow- erful than in acute articular rheumatism. Still, this is the treatment in which, from my own personal experience, I have the most confidence, when in addition, quinine is employed. Besides, this is a purely empirical rem- edy. I have frequently prescribed from thirty to forty grammes ( I 7.7 to 3 j. 3ij.) of carbonate of soda a day, during several weeks, with advanta- geous results. And, asl said when speaking of gout. 1 I i u the production of any symptoms of dissolution of the hh><><{ ; on the contrary, the patients often seem to have a certain teudenc; ater. By means of this treatment we are enabled to at least procure them a a amount of relief during the febrile exacerbations of the dia Tincture of iodine, internally, has been highly praised by Professor Lasegue. The dose has been steadily increased from eight to ten d] day to five or six grammes ( 3 j. gr. xviij. to " jss.), given during meals, the excipient being a little sugared water, or better, a glasf oish wine. The drug should be continued for several weeks, and, if necessary, foi eral months. Its infiuence has never given rise to any symptoms of iodine poisoning. ' Arsenic has been employed by Bardsley and Jenkinson, Begbie. Fuller and Garrod of England, and by Beau and Gueneau de Mussy of France. 2 Bardsley has administered this drug especially in eases oi chronic rheuma- tism located in the larger joints ; but the other writers, whose nam< - given above, have exhibited it particularly in cases of nodular rheumatism. I have myself tried this remedy in the SalpJtriere. and, like Garrod. have occasionally seen arsenic produce marked amelioration, and again result in complete failure. I think, however, that I am justified in affirming that 1 Arch. gen. de Med. Vol. ii. 1850. 2 Bardsley: Medical Reports. London. 1807. Kellie : RdL Vol. iii. 1S0S. J. Begbie (in same journal), No. 35. May, 1858. Poller: On matisni. Second edition. Loudon. 1^00. Gueneau de Mussy rapeu- tique. Vol. lxvii., p. 2L lSb'L Beau: Gaz. des Hdpitaux. July 10, 1- THE DISEASES OF OLD AGE. 165 arsenic is without any effect — indeed, is harmful even, in the most inveterate cases of nodular rheumatism, and when the disease has set in late in life. One of the first effects of its administration is frequently to reawaken the pains, and to make them much worse in those joints usually and most seri- ously implicated. Indeed, pain and swelling sometimes manifest them- selves in places where they did not previously exist, even compelling us to suspend for a time our treatment. Generally, however, tolerance is estab- lished at the end of a few days, and then the dose may be steadily increased. It is advantageous, in my opinion at least, to exhibit arsenic in the form of Fowler's solution in doses of from two to six drops, and this a short time after meals, according to the method in vogue in England. In France, while arsenic has been prescribed internally, it has likewise been employed in the form of baths by Gueneau de Mussy and Beau. In 1861, I made use of this method of treatment in the Lariboisiere Hospital. Ducom, the head pharmacist of that institution, very kindly undertook the analysis of the urine of those whom I had submitted to this mode of treat- ment, either internally or externally. In the first case, arsenic was found in the urine after a short lapse of time ; in the second the results were in all cases negative. Thus, it seems probable that these two methods do not act in the same way upon the organism, even if we admit that both are equally efficient in combating the disease — a statement that I am inclined to doubt. There is another drug which I have employed in cases of this kind, with results analogous to those from arsenic. It is the ammoniated tincture of guaiacum, which first produces an exacerbation of the local symptoms, and then marked relief ; the mobility of the joints reappears, and occasionally, after a certain time, the patient experiences evident amelioration. The iodide of potassium has sometimes been successfully prescribed in cases of chronic rheumatism. In chlorotic and debilitated individuals, iron and cod-liver oil may be indirectly useful by modifying the general bodily condition. The local remedies most frequently made use of are blisters, painting with tincture of iodine, and actual cautery (red-hot points). The latter is especially useful in the partial form of chronic rheumatism. Concerning mineral waters, Mont-Dore, Lamalou l'Ancien, Vals, Neris and Plombieres have all been prescribed ; most of these waters contain arsenic ; can it be that the efficacy ascribed them is due to this circum- stance ? We are far from having exhausted the long list of remedies that have been advocated for chronic rheumatism by various authors, or that we our- selves have tried. We have endeavored to bring prominently forward those therapeutical agents that to us seem possessed of the highest degree of efficacy ; but still we must acknowledge that chronic rheumatism is a disease which, in the majority of cases, baffles all the resources of medicine. 166 CLINICAL LECTURES ON APPENDIX. CLINICAL IMPORTANCE OF THERMOMETRY IN OLD AGE. 1 LECTURE XIX. Summary. — Importance of Clinical Thermometry in General — Its Application to Se- nile Pathology — Central Algidity — Normal Temperature in Old Age— Axillary and Rectal Thermometry — Bodily Temperature of Old People in Pathological Condi- tions — Extreme Limits of the Central Temperature — Low. Medium. \. but to a less extent musk (Wunderlich), and finally, curare, which, according and Liouville, produces an actual febn in which the t mper- ature may rise to 40° (10-4' Fain.). This is the appropriate occasion for a study of the variations in tem- perature produced by the action on the organism of morbid poisons, and animal or vegetable substances in process of putrefaction. The majority of putrid matters introduced into the blood in pi logical experimentation have the effect of elevating the central temperature and causing an attack of fever, accompanied by chills, acceleration of pulse- rate, loss in body-weight, etc. The experiments that recently have been repeated so many times by Billroth. Weber, Fischer, Bergmann and a host of other investigators, give almost the same results; and fever U not only by the injection of putrid materials, but also by the produi tissue-metamorphosis congregated, for example, in an intlamed wound, though there be no trace of putrefaction. 4 According to modern research, we know that traumatic fever is produced 1 Allgemeine Zeitschrift fur Psychiatrie. Bd. xxv., p. 686. Berlin. s Sidney Ringer : The Influence of Alcohol, etc. Lancet. 1866, p. 208. H. C. Gell and Sidney Ringer: The Influence of Quinine on th. perature of the Human Body in Health. ^Lancet. October 81, E 8 Brown-Sequard : Soeiete de Biohgie. VoL i., p. 103. 1848. II Wji of Poisoning by Sulphuric Acid. Arehiv der Heilkunde. Hef: 2 .gnan : Cas d'Empoisonnement par TAlcool. Gazette des Hopitaux. N 4 Venom seems to act in a similar manner. — Ca» of snake- (oobni I fully treated by sucking, liquor potassa), and brandy. John S 16, 1870. THE DISEASES OF OLD AGE. 187 in an analogous manner. The fluids thrown out from the surface of wounds, and loaded with products formed by destruction of tissue, pene- trate, by diffusion, through the walls of the lymphatics and veins, thus com- mingling with the blood. Thus it is they develop the febrile state by rea- son of this pyrogenetic power, the existence of which has lately been proved by experimentation. Experiments have likewise proved that the blood of a feverish animal, when injected into the veins of a healthy animal, induces fever. And even a rather profuse bleeding, which in a healthy individual has had the effect of producing a fall of temperature for a short period of time, may subse- quently produce a true febrile state. On account of the diminution of ten- sion occurring in the vascular system as a result of the loss, the products of the normal metamorphosis of tissue suddenly enter the circulation in great abundance, and there comport themselves after the manner of pyrogenetic substances. Such, at least, is the interpretation given by Bergmann and Frese, the investigators who conducted the experiments. ' It seems then to be established, that the majority of septic substances contained in pathological fluids have the effect of causing fever. But it is equally true that a certain number of this kind of substances have a dia- metrically opposite action upon the organism. Thus, for example, in the experiments of Weber and Billroth, the injection of putrid animal matter or putrid pus has very often determined a marked diminution in the tem- perature ; commonly this is followed in a short time by a more or less in- tense febrile condition, now persistent in character, and again, on the con- trary, progressively aggravated until death occurs, which, in the latter instance, generally ensues very quickly. It is difficult to absolutely predetermine what putrid matter will, when injected into the blood, produce fever, and what, on the other hand, will in- duce central algidity ; for, under the name of putrid or septic matter, are comprehended substances of the most varied chemical composition. It is, at least, very probable that the same substance which, taken at a given period of putrid fermentation, would cause fever, might, if used at a more advanced stage of the work of decomposition, induce the opposite result — algidity.. The principles whose presence in the putrefying matter may be determined by chemistry vary, of course, according to the nature of the substances whence they originated, and according to the different stages of putrid fermentation. Now, among these principles are some which, when separately injected into the blood, have the effect of lowering the bodily temperature. Such, according to the concordant experiments of Billroth, Weber, and Bergmann, are ammonia carbonate, butyric acid, am- monia hydrosulphate, and hydrosulphuric acid (sulphuretted hydrogen). If, then, there is a predominance of these agents over the pyrogenetic sub- stances in a fluid, we can readily understand what effect will be produced upon the organism by the injection or absorption of such a fluid. These data, taken from experimental pathology, are, we think, the key to a certain number of apparently contradictory facts that are observed in human pathology. There are, indeed, cases of septicaemia with fever, and others with cen- tral algidity. Occasionally, too, these seemingly opposite conditions may occur in succession in the same individual without the primordial phenom- ena being at all modified in their appearance. We may mention, in this connection, what is observed in cases of trau- 1 Centralblatt, Na 2. 1869. 188 CLINICAL LECTURES ON matic or spontaneous gangrene spreading over a large part of a limb. It has been shown, you know, that when the circulation of the blood has been completely arrested in a gangrenous limb, and when coagula have formed both in the arteries and the veins, the sphacelated portions may become a source of infection. Clinically we are already well acquainted with this fact, but the experiments of Kussmaul have placed this matter in the clear- est light. Under the skin of a limb thus apparently separated from the rest of the organism, he injected a certain quantity of iodide of potassium ; four hours later he detected traces of iodide in the urine. After this we may no longer doubt but that putrid matters from sphacelated parts can penetrate to the circulatory torrent. The phenomena of infection which they then induce sometimes manifest themselves by intense fever ; sometimes, on the other hand, by central algidity. We often notice within this hospital this succession of occurrences in cases of spontaneous gangrene, which usu- ally arise from an atheromatous or thrombic obliteration of the principal arterial trunks of a limb. If, in such cases, the patients resist infection for several days, and especially if the gangrene assume the moist form, the central temperature may progressively fall to 36 or Fahr.); in one case we even saw it as low as 34.. "5 ('.>4.1 Fahr. ). Here death occurred in the midst of symptoms of profound collapse : external algidity, cold sweat, almost imperceptible pulse, etc. How is it these substances are enabled to lower so rapidly and so con- siderably the central temperature ? It is supposed that they destroy a very large number of blood-corpuscles, or at least suddenly annihilate then- res- pirator power. In such cases, according to AYilhains' expression, or death of the blood is produced. Although they pn serve their pt character, the globules thus changed have lost their chemical j Should this alteration in the blood-disks be general, a rapid fall in temper- ature ensues. * Still, it is highly probable that, independent of this action, certain sub- stances affect the heart by paralyzing its movements. This happ the case of bile. "Whenever a certain quantity penetrai the blood, it simultaneously causes the heart to stand still and the t .re to fall (Leyden, Bohrig). Experimentation, to-day, has even . • far as to tell us what, among the very numerous constituents of the bile, are those which exclusively determine the slowing of the cardiac movements, and what are concerned with central algidity. Contrary to the ancient idea, we know that all of the bile — or at the principal fundamental constituents — passes into the blood in simple jaundice, such as that resulting from occlusion of the ductus communis choledochus. Now, in this spontaneous jaundice, as in experimental icte- rus, the elementary ingredients of the bile are found in the blood and ihe urine. In both instances, too, a slowed pulse and diminished of perature may be observed. Bohrig ' has proved that these results are due to the presence of the biliary acids ; injected alone into the circulation, they produce the same effects. Nothing like it, however, is caused by choleeterin, the coloring, or matters. By the sole fact of diminishing the number and strength of the heart's movements, the biliary acids may induce lowering of tl- ture. But Van Dusch and Kuhne have demonstrated thai sess the power of destroying the blood-corpuscles, and the I 1 Archiv der Heilkunde. 1863, THE DISEASES OF OLD AGE. 189 doubtedly contributes, in great measure, to produce a depression of the thermometric markings. 1 A remarkable fall in the central temperature likewise occurs in the ma- jority of cases of ursemia. 2 m. — After what I have just said to you concerning the mechanism by which lowering of the temperature is effected through the influence of the introduction of septic matters into the blood, you will not be astonished to find the same characteristic in certain organic or functional diseases of the heart. It is unquestionable that the majority of diseases which weaken the action of the heart tend to produce depression of the central temperature. "We can readily understand how flagging of the circulation, carried to a high degree, is a most unfavorable condition for the accomplishment of those chemical acts that maintain the bodily heat. It is also well known that when cardiac enfeeblement is carried to its utmost limits, as in syncope, the blood traverses the capillaries without undergoing any modification therein, and appears in the veins with the bright red color of arterial blood. Now in cases of this kind the central temperature falls, and is even markedly lowered in circumstances where matters are carried less far. Among the diseases of the heart itself that are accompanied by a dim- inution of the central temperature, I may mention, as an example, the case of rupture of the organ and extravasation of blood into the pericardium — a case we all saw in this hospital. One morning, in the dormitory, an old woman fell in syncope, and was immediately transferred to the infirmary, where we found her in deep lipothymia, which persisted nearly the entire day. A second syncope occurred just before evening, and death quickly ensued. During the long syncopal period between the two lipothymiss, the heart was feeble, frequent, and irregular ; the pulse almost impercepti- ble ; and the rectal temperature 36° (90.8° Fahr.). You are conversant with the fact that, incases of asystolism arising from organic diseases of the heart, there occur from time to time paroxysms characterized by feebleness and irregularity of the cardiac impulse, cyanosis and external algidity. During these attacks we have frequently observed the central temperature fall to 35° or 36° (95° or 96.8° Fahr.), and the par- oxysm once over, speedily returns to its normal standard. In acute peri- carditis and acute endocarditis, as we mentioned in our first lectures, we 1 Yirch. Archiv, xiv. 2 One of my pupils, Dr. Bourneville, has recently published a series of investiga- tions, whence it results that in uraemia — from whatever cause it springs (parenchyma- tous nephritis, pyelitis, cystic degeneration of the kidneys, calculous obliteration of the ureters, etc.), and whatever symptomatic form this blood-poisoning assumes (comatose, apoplectic, convulsive) — there is a constant lowering of the central tempera- ture. This fall increases as the nervous symptoms are aggravated, and, in some cases, the temperature has dropped below 30° (86 D Fahr.). In pueiyeral eclampsia, however, which some authors continue to ascribe to uraemia, Bourneville has observed a con- stant elevation of the temperature — an elevation that progressively increases from the onset until the fatal termination. 42° (107.6° Fahr.) has sometimes been reached under such circumstances. Besides, Bourneville has collected a certain number of observations relative to the modifications which the central temperature undergoes in cerebral apoplexy (hemor- rhage in, or softening of the brainy which confirm in every respect the results I have published. And further, having taken the hourly temperature in some apoplectic patients, he has demonstrated the influence, upon the thermometric curve, of the pro- duction of new hemorrhagic foci, or the effusion of extravasated blood into the ven- tricles. (See Bourneville : Etudes Cliniques et Thermometriques sur les Maladies du Systcme Nerveux. Paris, 1873.) 190 CLINICAL LECTURES ON sometimes notice a rise, sometimes a marked lowering of the central tem- perature. The same occurs in peritonitis. YVunderlich's observations are ample confirmation of the results we have thus far arrived at At a cursor j view it might appear strange to see a phlegmasia which some- times occupies a very large extent of surface — the whole of a serous mem- brane — induce a fall in the central temperature. Such is the case, how- ever : thus, pericarditis is superimposed upon lobar pneumonia ; it might be imagined this combination would result in a hyperpyretic ascent of the curve; but this does not occur. The curve either remains stationary, or, in the majority of cases, judging from oft-repeated observations, there is an unusual depression of the tracing. The production of such a depre- during the course of a pneumonia which up to that time has been regular, has often induced us to examine the heart with unusual care, and thus to recognize the existence of a pericarditis which, otherwise, would wholly have escaped us. Diaphrugmatic pleurisy f pneumothorax fr traumatic peritonitis — that arising from perforation and internal strangulation — likewise generally cause, momentarily at least, lowering of the central tem- perature. True, this is not an invariable result, but it is. nevertheless, quite a common one. Let me add that, in such cases, the central algidity may occasionally persist, or even increase until death, whereas in other in- stances it may give way to an excessive rise in temperature. However this may be, we need no longer be astonished to find, if we refer to the results of experimentation, a more or less violent irritation of the serous membranes, the peritoneum in particular, inducing such effects. You know very well that a blow over the epigastric region, the ingi of cold drinks when the body is covered with perspiration, 1 may bring about sudden death, apparently through the mechanism of syncope. Now, Brown- Sequard has shown that excitation of the semi-lunar ganglia" results in the production of syncope. According to him, this excitation of the ganglia is transmitted by the spinal cord to the bulb, is then reflected upon the pnea- mogastrics, which, irritated in their torn, cause the heart to stop in diastole. "When not carried so far as this, the excitation of the great sympathetic plexus niay determine a permanent diminution in the ■ and hence produce a more or less enduring kind of syncopal (Upothymic) condition, along with permanent lowering of the temperature. 3 It is undoubtedly by an analogous process that great concussion of the nervous system first manifests itself by a syncopal condition with on algidity, accompanied or not by subsequent reaction. Magendie has proved by experiments, which, Claude Bernard has con- firmed, 4 that all severe irritation of the peripheral nerves — such, for example, as the crushing of a limb entails — has the effect of lowering cardiac pres- sure ; the researches of Mentegazza inform us that in such cases the cen- tral temperature is diminished. 6 Following certain traumatic lesions of the cord, Brown-Seqnard has ob- 1 Consult on this subject the interesting memoir of M. A. Gtaerard: Bui lea denta qui peuvent succeder a Tlngestion des Boissoiis Froides. Annalea d'Hyg Vol. xxxvii. Paris. 1842. 2 Of the solar plexus. — L. H. H. 3 See Brown-Sequard : Archives de Medecine. Vol. ii.. pp. 44 \ 4^4. IS tures on Physiology and Pathology, p. 1 ol). Bernstein: H -ympa- thicus-Reizung. Centralblatt, Xo. 52. 1863, Ibid., No. 16. 1m>4. Eulenb. • Guttman: Patholog. des Sympathicus, in Archiv fur PBjchiatrie. Bd, ii.. Heft 1. 1809. 4 Lecons, etc. Vol. i., p. 20 7. 5 Schmidt's Jahrb. I,,l! THE DISEASES OF OLD AGE. 191 served profound collapse, complete suspension of reflex action, and the passage of red blood into the veins. At the same time there is a fall in the central temperature. IV. — We have just considered the principal circumstances in which the central temperature is lowered. Now, generally, when this thermic de- pression occurs abruptly, it manifests itself externally by coldness of the surface of the body, and by a train of other alarming symptoms. These signs, taken collectively, have been designated under one name, collapse, by Thierfelder * and Wunderlich, to whom we are indebted for a remarkable study on this clinical point — a point, it must be acknowledged, of which we have been too neglectful. 2 But collapse may likewise be produced in cases where the central tem- perature remains normal, or even rises above the normal limits ; and ac- cording as one or the other of these different forms is exhibited, the prog- nosis and the therapeutical indications will be found strikingly changed. Collapse is sometimes an almost certain forerunner of a fatal termination ; sometimes, again, it undoubtedly indicates a very grave state of affairs, but one that the well-directed resources of the art may, perhaps, carry to a fa- vorable issue. Finally, collapse is at times only an exaggeration of the phe- nomena which are nearly always observed, to a certain extent, when some varieties of febrile disease terminate with a rapid and favorable deferves- cence. From this simple expose it should be immediately apparent to you all how interesting to the clinician the study of collapse must prove, since, every time this group of symptoms is presented to him, there is a problem to be solved, a prognosis to be determined, a peculiar series of therapeutic means to be employed, and, let us add, all these within the barest limits of time, for the symptoms of collapse may only too soon terminate fatally. These phenomena are very commonly observed in the most diverse dis- eases of old age, and in those who are weakened by pre-existing maladies or by alcoholismus. But it is when supervening in the course of acute febrile diseases that collapse especially deserves attention. It is under such cir- cumstances that we desire to study it with you, and endeavor to determine its principal characteristics. Let us suppose a case of lobar pneumonia, and select a well-marked example. Up to the sixth or seventh day all has been in accordance with the established precedent ; the pneumonia is very severe, but it has devel- oped regularly ; the temperature is 39° or 40° (102.2° or 104 Fahr.), and the external phenomena of the febrile state are well developed. Suddenly, in the space of a few hours, the whole aspect changes ; the face is altered, the eyes deeply sunken, the cheeks and nose pale and icy ; the extremities are cold and cyanotic ; the body is covered with cold swea,t ; there is great prostration of the forces, and occasionally delirium may set in ; the cardiac impulse is feeble and irregular, the sounds seem dull and distant ; the pulse is thread-like, now accelerated, now retarded ; the respirations are rapid and deep. What is the signification of this very alarming ensemble of symptoms ? The exploration of the central temperature in such a case furnishes us 1 Archiv fur physiol. Heilkunde, 14te Jahrgang. Heft 2. June 15th. 2 In an excellent article, Chaleur, in the Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques. (Vol. vi., p. 808. 1867.) Hirtz has brought into prominent no- tice the interest which attaches to the study of collapse. 192 CLINICAL LECTUEES ON most valuable indications: first, if, at the very moment when the phe- nomena of external algidity are being produced, the central temperature is maintained at a high degree, or even rises to a hyperpyretic standard, death is certain. Indeed, dissolution has already begun. Soon it will no longer be a matter of doubt ; the pulse will continue to increase in fre- quency, and laryngotracheal rales quickly appear. Second, if, on the con- trary, at the same time the symptoms of collapse manifest themselves, the central temperature undergoes a marked diminution, or even descends to normal or slightly subnormal limits, the situation of the physician is more difficult, for at times the fatal termination may be already in preparation, and occur without much delay ; and again, on the other hand, convalescence may set in at the end of a few hours, and a bad prognosis, hastily given, will thus receive an express contradiction. It behooves us, therefore, to take into most serious consideration the indications offered by the other phe- nomena which accompany a diminution of the central temperature. When collapse is but the exaggeration of the ordinary symptoms of a rapid and favorable defervescence — when, at the same time that the central temperature falls, the respiratory movements and arterial pulsations be- come slower and regular, the prognosis is good, even though some alarm- ing symptom, such as violent delirium, supervene. 1 When, on the other hand, the central temperature falls, and the fre- quency of the pulse and respiratory movements continues or inn situation is very grave indeed. Death will very soon supervene. d< every effort that may be made. And although we were but recently led to give a favorable prognosis, even when intense delirium was an accompani- ment, yet here we must maintain an equally unfavorable one, in spite of the defervescence producing a feeling of comfort in the patient. Such was the case of a woman, fifty-four years old, enfeebled by uterine carcinoma, who had an attack of lobar pneumonia — a case we had in very wards. About the seventh day of the pneumonia, at the moment when rapid defervescence occurred, this woman experiei. uliar sensation of well-being, which has deceived many of you, but which very soon suc- cumbed to the death-struggle. This is the collapse, which in croupous pneumonia takes place at the period of defervescence as the most usual occurrence. But the same group of symptoms can appear at any stage of the disease. At the acme of the malady, collapse results in the majority of c from some complication, such as pericarditis, violent diarrhoea ; or rather, in the aged, it appears from too marked an action of a drug, as tartar emetic or digitalis. The prognosis you will give varies very much in this class of c It depends particularly upon the influence of the means employed to com- bat the complication, or to repair the damages caused by ill-timed medica- tion. Again, collapse may manifest itself from the commencement of a pneu- monia ; in such cases it is usually transitory, soon giving way to a more or less marked reaction ; at other times, however, it persists during the whole course of the disease, which then commonly ends most unfavorably. This algid pneumonia is quite rare, even among the ly debili- tated subjects whom we meet with in such great numbers within walls. Many of you, however, have perhaps observed a remarkable exam- ple of this in our wards. The woman, L , seventy-oiu :' age. 1 Weber: Med. -Chirurgical Transactions. Vol. xlviii. l v THE DISEASES OE OLD AGE. 193 when attacked with lobar pneumonia, presented from the onset, and during the whole period of the disease, a series of symptoms which made it resem- ble cholera. The extremities were cold and extensively cyanotic, the face was livid, the eyes deeply sunken, and the voice very faint. There was no diarrhoea. The alvine evacuations were rather scanty ; the urine was pale, diminished in quantity, containing quite a large proportion of albumen. The rectal temperature osculated between 38° and 38.4° (100.4° and 101.1° Fahr.), never reaching 39° (102.2° Fahr.). The pulse, feeble and almost imperceptible, was between 100 and 108. At the autopsy, the lower and middle lobes of the right lung, throughout their whole extent, presented the most classical characteristics of red and gray granular hepatization ; and the lung itself weighed nearly one thousand grammes more than the left (2 pounds 3^ ounces avoirdupois). The kidneys offered no appreciable change. This variety of collapse constitutes one of the characteristics of the sideral form of the majority of pestilential diseases, contagious and infectious fe- vers ; thus, we observe it in yellow and typhus fever 1 and in the plague ; it is also met with in paludal (malarial) poisoning. 2 I have often seen it in the small-pox of the aged, where, as you know, it frequentty assumes the hemorrhagic form. In such cases, at the very moment when the blackish pustules appear upon various parts of the body, the extremities become cold and cyanotic, the prostration of the forces reaches the utmost limit, and the temperature in the rectum varies between 36° and 37° (96.8° and 98.6° Fahr.). I am far from having exhausted the subject I purposed to discuss before you, but I fear to weary your attention by multiplying examples ; besides, I have said enough, at least so I hope, to demonstrate to you the exceed- ing interest which attaches to thermometric studies in the clinic in general, and especially in the case of old age. 1 Charcot : Articles Typhus Fever, The Plague, Yellow Fever, in the fourth vol- ume- of Elements de Pathologie Medicale. By A. Requin. Paris, 1868. " In algid pernicious fever. Griesinger • Traite des Maladies Infectieuses, p. 64. Paris, 1868. 13 194 CLINICAL LECTUBES ON LECTUKE XXII. SENILE PNEUMONIA. Summary. — Introduction — Morbid Anatomy — Symptoms — Etiology. Gentlemen : — In our northern climate, diseases of the respiratory organs are the most common and fatal of the diseases of old age. That we niay study this class of diseases intelligently, it is necessary that we should be familiar with some of the more important anatomical and physiological differences in the lungs in adult life and in old age. The rarefied condition of the lungs in the aged, their increased light- ness, the dilatation and rupture of the air-cells, their diminished elasticity, the obliteration of large numbers of their capillary vessels, and the diffu- sion of carbonaceous matter throughout their substance, tend to modify the pathological changes which occur in the pulmonary diseases of the aged. The lungs in fleshy old people are of an ashy gray color, studded with black spots and lines. The surface of the pleura is less moist than in adult life. Externally the lungs resemble those of adults ; but they crepi- tate less and have a more elastic feel. The fissures between the lobes change their position, so that in the left lung the upper lobe is in front and the lower behind, and in the right lung the middle lobe projects down- ward, the lower one rising behind it, so that it forms a considerable por- tion of the summit of the lung : thus, pneumonia of the apex may really have its seat in the lower lobe. Microaxpicauy the air-cells are about double the size of normal adult lung-cells. In emaciated old people, though the lungs are much the same as in the fleshy, they cannot be perfectly inflated ; they are bathed in serum ; the and lines are more distinct, and they crepitate much It Again, the lungs of the very aged may present a livid appearance, the apex being larger than the base. Their surface is uneven and look- they were "crumpled," and they are surrounded by a large quantity of fluid, which fills the space caused by their wasting : they cannot be fully inflated, and the respiratory murmur is very feeble. They lie close to the vertebral column. Their specific gravity is much less than that of the adult lung, and the lobes are occasionally attached to one another by pedicles. The alveolae have no definite form, and* the cells are very large. The bony thorax accommodates itself to these atrophied, shrivelled lungs. With advancing years the vital capacity volume d< nfl ^ith tolerable regularity. The rate of diminution has been estimated to be about one and a half cubic inches each year. During each hour a healthy adult exhales about one thousand three hundred and forty cubic inches of carbonic acid ; now. between I THE DISEASES OF OLD AGE. 195 sixty and eighty the amount, in men, falls to about nine hundred and thirty cubic inches each hour, and in very old men it has diminished even to six hundred and seventy. The same physiological difference exists between the sexes in old age as in other periods of life; thus, women in the sixties exhale only six hun- dred and seventy cubic inches of carbonic acid an hour, and this continues to decrease in a proportion similar to that in old men. The precise changes which occur in the interchange of gases in the lungs in old age are not very well understood. The respiratory activity, the depth, and the force of the acts, all are much less in old age than in middle life; and the predominance of venous blood is a marked feature of old age. Finally, what the French call "besoin de respirer" — want of breath — in- creases perceptibly as years pass. With these facts before us, let us study the anatomical changes which take place in the pneumonia of old age. In our climate it is the most fatal inflammatory disease of the respiratory organs in the aged. The mortality rate in those over sixty years is about eighty per cent. For this reason, and on account of the very great differences in the disease when it occurs in adult life and in old age, I shall enter into its history somewhat in detail ; at least, I wish to make pneumonia in old age a subject of special impor- tance in the few lectures which I shall add as a supplement to the inter- esting and instructive lectures of Professor Charcot on Diseases of Old Age. Its morbid anatomy may be divided into three stages : a stage of en- gorgement, of red hepatization, and of gray hepatization. In the aged the morbid changes usually begin in the upper lobes, the disease extending downward — the reverse, you remember, of what occurs in adults. Engorgement. — This stage resembles that of the adult pneumonic lung — the dark red color, the firmness, the pitting on pressure, the doughy feel, and increased weight, all are here. They do not sink in water, the loss of crepitation is far greater than in adult life — indeed, often entirely absent. On section, a bloody serum exudes, and flows much more freely from the cut than in adult pneumonia. It is now (comparatively) very friable. This is the only change which you will find in many cases of " sudden death " in pneumonia of the aged. It is often called congestion of the lungs, and by its gross appear- ance alone it is difficult to differentiate between this stage of pneumonia and congestion ; but a microscopical examination reveals, in pneumonia, the air-cells filled with a markedly viscid fluid, which, on the addition of alcohol, coagulates into an amorphous, granular substance, containing a number of red blood-globules. The diminution of the lumen of the air-cells by the enlarged capillaries is not well shown in senile pneu- monia. In pulmonary oedema the fluid in the air-cells is simply serum ; in pneu- monia it is an inflammatory exudation. In the stage of red hepatization the lung is of a deep red color, darker than is usual in adult life, no longer crepitates, and' has a distinctly " marbled " appearance, heightened by the dark lines and dots that are present in its normal condition. The color is sometimes a bright blue or black. The lung sinks in water with a rapidity proportioned to the degree of consolidation, but it rarely falls to the bottom of the vessel, indeed, it frequently remains near 196 CLINICAL LECTUHES OX the surface ; this lightness in the second stage of senile pneumonia is ex- plained by the rarefied condition of the lungs in the aged. On section, the cut surface may present either a granular or a non- granular appearance. The granules are much larger than is usual in pneu- monia at any other time of life, and, when not irregularly developed, they exhibit a tendency to commingle. Bloody serum exudes from the surface of the cut. Red granular hepatization is very much more common in old age than the non-granular, and the friability is much less than in adults. A microscopical examination shows the large, irregular air-cells to be filled with organized fibrin, red blood-globules, leucocytes, and changed epithelial cells. In the stage of gray hepatization or suppuration, the lungs are still con- solidated. On section, the cut surface presents a marbled drab, or " granite " look, and a copious flow of yellow, opaque pus exu.i There is more friability than in the second stage, and the lung breaks down on slight pressure, which reduces it to a grayish pulp. The microscope shows the presence of a greater number of leucocytes, and the young cells to have undergone fatty degeneration; the fibrinous plugs having disintegrated, the outlines of the granular elements within the alveoli are indistinct. These processes may terminate in resolution, gangrene, or abscess. When resolution occurs, the alveolar contents undergo such a fatty or mucoid degeneration that they are readily absorbed. Pigment, either from the blood or the interlobular connective tissue, often stains the masses, and appears in the expectoration. The lung i - gray-white in color — never granular — and a viscid, purifonn fluid can be squeezed from the cut surface. Senile pneumonia terminates in gangrene much mart frequently than adult pneumonia. You may find all or part of a lobe of the lung gangrenous. "When partial, the gangrene may be limited by an inflammatory zone, or diffused irregularly. The gangrenous cavities, when near the surface, often cause sloughing of the adjacent pleura, and in nearly all cases the lung-cavity contains a quantity of blackish green, fetid pus. The walls commonly consist of a shreddy material, and vascular bands pas the cavities. Myriads of bacteria are found in the fluid contents. The rarefied condition of the lungs in old age seems to favor the de- velopment of those small abscesses that are so common after a senile pneumonia. We occasionally find them interspersed throughout the con- solidated tissue, several of the alveoli intercommunicating. Large abscesses may break into a bronchus and establish a vomica, and, if superficial, may lead to pyopneumothorax. An external fistulous opening never occurs in advanced life. Large ftbfi ie result of the c cence of several smaller ones, containing, besides pus. pulmoni are rare in old age compared with the disseminated small om - abscesses are preceded by intercellular oedema. In old age, though the right lung is more frequently involved, the difference is far less striking than in adult life. Some obsef that sthenic pneumonia generally occurs on the right, and typhoid on the left side. ■ Senile pneumonia is invariably accompanied by inflammation of the THE DISEASES OF OLD AGE. 197 minute bronchi, so that it may be difficult to differentiate between a catar- rhal and a croupous pneumonia. The pulmonary pleura is much less fre- quently affected in old age than in adult life. The lymphatics of the lung are choked with fibrin, red and white blood- globules, and a few endothelial cells ; while the deeper lymphatics contain products identical with those of the alveoli. Etiology. — The predisposing causes of senile pneumonia are : the age- degenerations, persistent bronchitis, and passive congestion from valvular and other diseases of the heart. Occupations where sudden changes of temperature occur, and hence, climates where a like condition is present, predispose to its development ; all enervating habits, poverty, intemperance, and dyscrasiae, act as power- fully in old age as in adults. From November until May nearly nine- tenths of the recorded cases of senile pneumonia have occurred. Bright's disease, pyaemia, and septicaemia are among its predisposing causes ; but the last two rarely occur in advanced life. A recumbent position, long continued, may lead to pulmonary hyperaa- mia, and thus predispose to pneumonia in the aged more so than in adult life. Sex is not so markedly prominent as a predisposing cause of senile pneumonia as at other periods of life ; indeed, the cases are pretty equally divided between old men and women. The most frequent exciting cause is cold ; and dry, sharp cold seems to act, judging from reliable statistics from hospitals for the aged, much more powerfully than moist cold, which rather induces bronchitis. Fracture of the ribs, pleuritis, and pericarditis excite pneumonia ; and it is noteworthy to observe how often, in the aged, such an accident as in- jury to the hip-joint, for instance, is followed by a pneumonia. It must, I think, be reckoned among the exciting causes, since, even as soon as four hours after the receipt of the injury, the disease is sometimes estab- lished. Lastly, uraemia and certain atmospheric influences, malarial and septic, excite pneumonic inflammation, and " sewer-gas " pneumonia is quite fre- quently developed in advanced life. Symptoms. — Senile pneumonia commences very insidiously, and usually runs a latent course. In a few cases it commences with well-marked symptoms in the midst of perfect health, and without any apparent existing cause ; or, as in the adult, flying pains in the limbs and chest, occasionally epistaxis, loss of appetite, and a feeling of general 'malaise, may be the precursors of its development. When intercurrent, senile pneumonia is always latent. It may begin with a protracted attack of shivering — rarely a distinct chill ; when an old person has a distinct chill, pneumonia almost invari- ably follows ; for, though less frequent, it is yet more important than in adult life. The same may be said of pain in the side. According to statistical records from that vast asylum for the aged — The Salpetriere — it is in March and April that these two symptoms almost always occur, and then the disease assumes the sthenic type. Again, when there is no shivering or pain — which occur in only about half the cases — the onset may be marked by a very slight increase in, or irregularity of, the movements of respiration, a slight elevation of tempera- ture, a feeling of great exhaustion, and a short, hacking cough. In some 198 CLINICAL LECTURES OX cases even all but the feeling of weakness are absent. It mar be ushered in by nausea, vomiting, diarrhoea, and collapse. When an aged person, suffering from chronic bronchitis or asthma, de- velops a pneumonia, you will very often observe that the cough and diffi- cult breathing which were induced by either of these conditions, undergo remarkable diminution, and the aged patients are scarcely ill ; they get up, walk about as usual, perform their meagre daily work, he down on their beds feeling a "little tired," and suddenly expire. You meet such cases most frequently when chronic cardiac or cerebral disease coexist, al- though they do not necessarily cause a latent pneumonia. When not latent, senile pneumonia, once established, progresses with the following symptoms. The respirations are accelerated ; but, as old j^eople rarely com- plain of dyspnoea, you must count the chest-movements very carefully to recognize the change. There may be a cough, although at times it is so slight as to escape the notice of the physician, nearly always that of the sufferer. There is pain in the head, usually in the frontal region ; and this pain ma} r be followed by a mild delirium, especially toward evening, there being usually more or less disturbance of the intellect, while stupor or a coma, from which it is momentarily impossible to arouse the patient, comes on and continues throughout the disease. The face is flushed, sometimes more so on the side of the inflamed lung than on the other. The pulse is accelerated, the temperature is elevated ; and in all c on taking the temperature, the thermometer should be inserted in the rec- tum, for, as Charcot Bays, in the aged there is v* ry often a marked difl ancy between axillary and rectal thermometry, the latter only showing the true heat of internal viscera. There is great prostration, and the appetite is impaired, while thin increased. I shall now consider the individual Bjmptoma more in detail, and separately. By far the greater number of pneumonic patients who are advanced in life, cough ; and the cough, although in the main short, hacking, and pain- ful, yet undergoes greater variations in intensity, frequency, and character, from the fact that in old age pre-existing pulmonary or bronchial affections are so very common. Expectoration, — In old ag< ration d ir early, and. even when it does, is liable to sudden suppression. First scanty, gray, and frothy, then yellow or " catarrhal,*' it finally may become reddish, glutinous, or viscid. The red color is never so marked as in adults ; but 1 '. sputa may accompany acute senile pneumonias whose onset — these are fatal cases. In the majority oi cas uta resemble I of bronchitis, the color being opaque, yellowish green. Purely puriforni sputa never occur in the pneumonia of old age. Expectoration is always difficult, and is even absent in asthenic, masked forms of the disease ; it is rare to see classical variations in the sputa of the aged, such as we witness in those of adult life. Toward the close of the disease the expectoration becomes prune-juice in color ; but a choc looking serous sputa may occur soon after the onset, and i symptom, denoting, as it does, a depraved-blood conditio: pneumonia." THE DISEASES OF OLD AGE. 199 A watery, blood-stained, or prune-juice expectoration indicates either a severe and dangerous form of pneumonia, or pulmonary congestion and oedema. The reason of the non-appearance of the viscid, pathognomonic sputum in pneumonia of advanced life is the rapid transition of the stages— puru- lent infiltration taking place early. A microscopical examination of the sputum reveals all the elements de- scribed in its pathology as filling the alveoli, and sometimes it affords one of the chief means of its diagnosis. In asthenic typhoid pneumonia, where the expectoration is slight, it ceases altogether with increasing prostratio?i. The sputa contain an excep- tionally large amount of sodium chloride. Finally, the appearance of creamy, abundant sputa on the day of crisis does not hold in old age, since expectoration may be catarrhal from the on- set, and throughout its course. The rectal temperature rises to 103° F. or 104° F., sometimes higher, on the first days. Except by the temperature range it is often difficult to determine the exact day of the invasion of senile pneumonia. With daily morning and evening oscillations of a degree or a degree and a half, it con- tinues for three or four days at about the initial point. The rise in tem- perature does not begin for several hours after the initial chill, if a chill occur. The temperature may rise progressively, with slight intermittent remis- sions ; or it may suddenly fall, the tracing giving an almost perpendicular line. Both these occurrences are common in senile pneumonia, the first ending in death in the vast majority of cases ; while the second, called the defervescence, tends sometimes toward recovery, sometimes toward dissolu- tion. When the onset can be approximately estimated, the temperature will be found to be highest on the third day, unless fatal defervescence occurs. The pulse in the aged is normally more frequent than in adult life. In old men the average normal pulse is froin sixty to seventy beats per min- ute, and in women from sixty-eight to seventy-eight. This is the rule, al- though in a few instances you may find marked slowness of the pulse-rate in healthy old men and women. Hence, in senile pneumonia the pulse does not afford reliable indications ; for the rate, in this disease, might be only fifty, and yet this might be a rapid pulse in this particular instance. When normal, the pulse is from seventy-three to seventy- eight ; you rarely find any increase when the pneumonia begins. On account of the arterial changes in old age, it is best to count the pulse at the heart. In the pneumonia of adults the pulse is " full," but in old age the pulse has, normally and in disease, a fictitious hardness ; when the heart is intermittent the radial pulse may not represent any intermittency or ir- regularity, and on the other hand it may become feeble and intermittent while the heart is normal and acting with regularity. The action of cold to the surface in the aged is very quickly indicated by the radial pulse, diminishing its volume and strength ; so, if the pulse at the wrist be taken, it should be from the hand that has been under the bed-clothes. Finally, although the pulse may rise to one hundred and twenty beats or more per minute in senile pneumonia, still it must be regarded as an untrustworthy g-uide. TJie respiration. — In old age the work of the respiratory organs seems 200 CLINICAL LECTURES ON to diminish with that condition of the lungs of which I have previously spoken. The diaphragm is the chief agent in respiration. The scaleni muscles and the sterno-cleido-mastoid becoming nearly useless, you will very frequently notice the head to be thrown back during inspiration, and the whole act of inspiration is imperfect and more or less difficult. In inspiration in the aged, the enlargement of the chest is chiefly verti- cal ; there is no lateral movement whatever. Expiration is sudden and rapid, as a rule ; the whole act, however, is of a "panting" character. The number, on the average, of respirations, is twenty-two ; and inspiration is to expiration as six to eight or nine. Very often the inspiratory movements, in old age, are " jerky M and in- terrupted, the lung becoming expanded only after a succession of efforts. This occurs in perfectly healthy individuals. There is a marked diminution in the vital capacity of the lungs of the aged. Again, the altered condition of the mucous membranes of the whole respiratory tract, from imperfect vascular supply, probably interferes with the proper excretion of aqueous and other vapors. For this reason pul- monary oedema is readily set up in senile lungs. The proper amount of excretion does not take place, and hence the fetid breath which is met with in so many old people. As has been mentioned, old people with pneumonia rarely complain of difficulty in breathing ; and you may notice the acceleration in the num- ber of respirations oftener, by palpating the chest than by direct obser- vation, for the respirations may vary from thirty to seventy per minute, and yet no actual dyspnoea exist. As in the adult, the degree of dyspnoea is directly proportional to the extent and severity of the pneumonic process, except in pneumonia of the apex, when there is always intense dyspnoea, so much so that severe dysp- noea in the aged should always direct you to a physical exploration of that part of the chest. " Catchy " breathing — a mere exaggeration of what is physiological in old age — is one of the most frequent forms of abnormal respiration, in the pneumonia of advanced life. When dyspnoea is very intense, and the pneumonia is at the base of the lung, it tells of nervous exhaustion, and is very serious. As you will remember, the general causes of dyspnoea in pneumonia are the diminution of the breathing surface ; the influence of the fever ; the pain, which is exacerbated by movements ; the enfeebled heart-power ; and the greater demand for oxygen, on account of the rapid tissue-metamor- phosis. Pain. — Even in pleuro-pneumonia of the aged, pain is never very in- tense ; it is rather an uneasy, dull feeling, occupying no particular and very frequently is diffused over the whole chest. Tenderness on palpation or percussion is not so marked as in the adult. Pain, if present in senile pneumonia, is referred to various local: the pit of the stomach, the region of the xiphoid cartilage, the nipple, the loins, the hypochondriuni, or even the side opposite to that which is the seat of the pneumonic process ; but it is always anterior. In pneumonia at the apex it is transitory or completely absent. In "typhoid" pneumonia there is no pain; but, as the disease pro- gresses, a sense of " oppression M occurs, which increases with the inert weakness. THE DISEASES OF OLD AGE. 201 One side of the face, more than the other, has a " mahogany " colored flush upon it, not diffused as in typhus fever, but as a circumscribed spot. This flush is often the first objective sign of senile pneumonia. The heat of the skin is greatest in the morning. Three or four days from the onset of the pneumonia, herpetic eruptions appear upon the cheeks, lips, and nose. If the lips become blue, it denotes vaso-motor disturbance, and is a very grave sign. As the disease advances, the face loses this dusky hue and becomes sallow — a very dangerous symptom — and the surface-heat gives place to a cold, clammy perspiration. At my next lecture I shall continue the consideration of the objective symptoms and physical signs of senile pneumonia. 202 CLINICAL LECTUKES ON LECTURE XXIII. SENILE PNEUMONIA— ffontfntutf. Summary.— Symptoms — Physical Signs — Differential Diagnosis — Prognosis — Treat- ment. Gentlemen : — Headache usually lasts throughout an attack of senile pneumonia, and is apt to be accompanied by delirium of a mild type, when the apex is the seat of the inflammatory process. In asthenic, typhoid. or " nervous " pneumonia, there is low, muttering delirium, and a constant desire to get out of bed. These symptoms, however, do not of themselves indicate any serious cerebral disturbance. Of the symptoms referable to the alimentary tract, anorexia is the most constant ; and, while patients do not express a desire for drink, they yet take with avidity the fluids which are put to their lips. The tongue at first is whitish ; later on it becomes dry. shrivelled, and coated with a thick, brown fur, and is protruded with difficulty. The teeth, gums, and inside of the cheeks are likewise covered with thick, brown sordes. The stools are dry. and, as a rule, the bowels constipated. Some think that the Hver undergoes passive hyperemia during a pneu- monia, the mechanism being the same as in certain cardiac derangen and thus they account for the jaundice which so frequently accompanies senile pneumonia. But it is more in accordance with to-day*! pathology to regard the jaundice as of hematogenous rather than of hepatogenous origin ; caused, in other words, by a change in the blood itself, the direct result of the pneumonic process. Jaundice is more frequent in cases where the pneumonia is located at the apex. The urine is scanty, dark red or brown in color, and of high specific gravity. Bile-pigments are found in it. There is an increase in urea, and, on cooling, the urine becomes turbid from precipitation of the urates. The most characteristic change is the great diminution of chloride of sodium. Albumen may be present, and the higher the temperature, the more albumen may we expect to find, other things being equal. The signs which indicate the mode of termination of senile pneumonia vary. If a case is tending toward a fatal termination, the face becomes sallow ; the skin cold and clammy ; the ala^ nasi and extrinsic muscles of respiration are called into play ; the heart becomes feeble, rapid, irregular and inter- mitting ; the temperature either rises rapidly or falls quickly and continu- ously ; the inspirations are gasping, there are groat apathy and somnolence, and gradually coma comes to usher in the fatal issue. You may sometimes hear, at a distance from the patient, the rales which result froni that a of the lungs which comes from heart-failure. THE DISEASES OF OLD AGE. 203 When resolution occurs in senile pneumonia, it is generally by crisis. The temperature falls suddenly, sometimes below normal ; there is a return of the appetite, a general feeling of returning comfort, and if there has been prune-juice sputa, the red color disappears and a catarrhal expectora- tion takes its place. This, however, is not a very frequent termination of senile pneumonia. Convalescence is slow, months elapsing before complete recovery is reached. If the pneumonia terminates in gangrene, typhoid symptoms appear very early. The face is generally pale, sometimes of a deathly hue ; the eyes are sunken, the breath is fetid, and the whole body emits a cadaverous odor. The sputum, if present, is of a blackish green color, of a putrid odor, and contains shreds of decomposed and decomposing lung-substance. If pulmonary gangrene is a sequel of pneumonia, death occurs with symp- toms of the profoundest collapse, usually within five days from the time of the initial chill. The formation of abscesses in senile pneumonia is never evidenced by any well-marked symptoms. There may be rigors and hectic ; the expec- toration may become purulent, copious, and of a grayish tint, sometimes con- taining fibres of pulmonary tissue, with the physical evidences of a lung- cavity. Finally, before studying the physical signs of senile pneumonia, there remains a not unimportant variety which is called bilious 'pneumonia — an unfortunate name, since the term bilious is too often, at the present day, applied to any group of symptoms that seem to have some connection with liver derangement. Diarrhoea and vomiting are present in this form, and occur very early. The vomiting is " bilious" in character, and icterus is generally more or less strongly marked. Somnolence and stupor like- wise may occur in this form, which is an extremely unfavorable symptom. Another variety, which is peculiar to old age, is remittent pneumonia. All the symptoms, after energetic treatment, cease for a time — to return, however, with greater severity the next day ; and as this lull in the disease seems most promising, a prognosis might be given which would suffer em- barrassing contradiction in the future developments of the case. Physical signs. — Before the physical signs of senile jmeumonia can be accurately estimated — if, indeed, this is possible, the physiological modifica- tions of old age must be carefully considered. Eespiration, as has been said, is mainly diaphragmatic in old age ; the average number per minute is from twenty-one to twenty-two, and inspira- tion is to expiration as six to nine. The physical signs are modified by the bony union of the different parts of the sternum and ribs, by curvature of the spine that is generally well marked in old age, by the rigidity of the bronchial tubes, by the rounded form of the chest in advanced life, and, finally and most impor- tant of all, by that rarefaction of the lungs to which reference has been made. Percussion. — From the above-mentioned considerations, one would ex- pect, what actually occurs — a very clear percussion-note, and occasionally one that, compared with an adult chest, is abnormally resonant. When the air-cells have ruptured to any considerable extent, you may elicit, on firm percussion, a resonance as well marked as occurs in slight adult emphysema (the reverse of what occurs in middle life); the clavicular region near the median line gives a dull percussion-sound on account of the great arching of the sternum and the great deposition of carbona- ceous material at the apex of the lungs. 204 CLINICAL LECTURES ON The infra-clavicular and mammary regions are extra-resonant. The lungs being pushed back to the spinal column, the sternal region is less resonant, and may often sound almost dull ; the heart-liinits can be accurately marked out, on account of its being uncovered by lung-tissue. The scapular and supra-scapular spaces are less resonant than in the adult, on account of the tilting of the scapulae, due to curvature of the spine. Auscultation. — There is a loss in the vesicular element of the respiratory murmur in old age. The respiratory sound resembles closely that pro- duced by a rather forceful expulsion of air from the compressed lips, and is diffuse in character, sounding as if the incoming column of air met a thinned and readily vibrating membrane ; the murmur is louder and less soft than in adult life. In lungs where the septa are torn and the alveoli greatly distended and irregular, the respiratory sound is bronchial in character. The intensity of the respiratory murmur in old age is variable : at one moment it is loud, at another, hardly perceptible ; and it varies not only thus in the same individual, but also in different individuals of the same age and condition of body. The voice-sounds are very loud ; occasionally there is even bronchophony, and in very extensively atrophied lungs this bronchophony has a vibrating or catching character, causing it to resemble very closely cegophony. Finally, it is an almost -physiological condition for old people to have a bronchorrhcea ; hence, mucous rales may be constantly present during the whole period of advanced life. To the physical signs of pneumonia one always turns for confirmation of his diagnosis, but here one will be misled who has in mind only the usual adult signs. Fikst Stage. — Inspection and palpation in the first stage of senile pneu- monia furnish little positive information. Percussion may reveal slight dulness ; this is very rarely the case until the lung has reached the stage of red hepatization, and even then it may be so slight in character as to leave grave doubts of its existence. Auscultation. — Very early in the disease the respiratory murmur is feeble and indistinct over the affected portion while the lung that is not involved assumes for the time all the characters of a normal adult respiratory mur- mur. Again, the breathing over the pneumonic spot may be intense' and in such a case will usually be rough, interrupted, or broken in char- acter. Tubular breathing may sometimes be heard at the root of the lung, and then the respirations are generally markedly feeble. A peculiar bronchial souffle is often heard over the inflamed lung, and in some cases this is audible in the superior sternal region. As soon as the pneumonic exudation occurs in the adult, the distinctive crepitant rale is heard, but in advanced life a distinct crepitant rale in the first stage of pneumonia is rarely present But subcrepitant rales, and large, moist rales, resembling to BOOM tent what we hear in capillary bronchitis, but oftener analogous to the rales of a simple bronchitis, are heard during the period of exudation. The reason for the almost invariable absence of the crepitant i seems to me. to be found in the physiological condition in old age ; the alveoli are dilated, their walls are thinned and frequently perforated, and the lungs themselves are retracted from the chest-wall. THE DISEASES OF OLD AGE. 205 Sometimes, when you make the patient cough violently for a few min- utes, and then have him take a deep inspiration, you may hear fine crepita- tion ; but, upon closer examination, it will still be found to be subcrepitant in character, in no wise differing from that of capillary bronchitis." Soon the crepitation, whatever character it may assume, extends over the chest, from the general bronchitis that so soon accompanies the dis- ease, and masks, in whole or part, the respiratory sounds. It may be stated, as a general rule, that the feebler and more superficial the respirations, the less distinct will be any adventitious sounds. The dilation and rigidity of the bronchi that are physiological in old age, of course favor the development of bronchial breathing, which, indeed, is oftentimes the first physical sign of the pneumonia. One of its peculi- arities, when occurring in the stage of engorgement, is that it is limited to the root of the inflamed lung. Hence, this is an important sign, and one that should be always listened for in all doubtful cases. In the unaffected lung the breathing is often puerile, and sometimes accompanied by dry, transitory bronchial rales ; and in a few exceptional cases, when the lower lobes are involved, the upper give evidences of hyperemia. Adjacent to the inflamed portion the respiratory murmur is very much weakened. Second Stage. — Inspection in some cases reveals diminution in the ex- pansibility of the affected side, but this is not constant. Palpation may or may not show increase in the vocal fremitus. Percussion. — What is dull in old age might be regarded clear in the adult ; hence, when dulness on percussion is said to mark the stage of con- solidation, the term is only relatively true. Still, when superficial, there may be actual as well as relative dulness. The dulness is best marked posteriorly. Auscultation. — Tubular or bronchial breathing marks the second stage of senile pneumonia, and the sounds are even more intense than in adult life ; small gurgles or mucous rales generally persist throughout this stage. Bronchophony is not very well marked, even when present ; while segophony, from the quavering voice in advanced life, is far from infre- quent. Third Stage. — Inspection gives negative results. Palpation may or may not reveal increase in the vocal fremitus, accord- ing as it was present or absent in the previous stage ; but in general vocal fremitus decreases. Percussion shows the dulness to be decreasing — the chest again becoming very resonant. Auscultation shows the crepitating sounds to be louder ; and the gurgles loud and large, often heard at a distance from the pneumonia. The rdles redux, then, are not, as such, distinctive of, or peculiar to the third stage of senile pneumonia. The sound heard at this period of the disease is called a muco-crepitating sound, by which is meant a form of sub- crepitant rale produced in tubes intermediate between the bronchioles and the larger bronchi. Finally, as has been hinted, the physical signs of pulmonary abscess in the aged are very generally wanting ; distinctly localized gurgling and cavernous respiration may, when taken in connection with the rational signs, suffice for an approximate diagnosis, but the great rarity of abscess in old age should make us cautious in its diagnosis. The sputa will greatly aid us in such a case. 206 CLINICAL LECTURES OS The physical signs of senile pneumonia are subject to greater variations than ever occur in pneumonia in the adult ; and often they do not even follow the course, irregular as it is, that I have just described. Gray hepatization, or abscess, may be reached without any distinctive auscultatory signs being heard, even on repeated and careful examination. Even in "resolution " the rale redux may be absent ; dulness and bron- chial breathing being immediately followed by normal (senile) resonance, without crejiatation. This occurs most frequently in the M typhoid " variety. Differential diagnosis. — The question very naturally senile pneumonia be diagnosed if it may run M without either expectoration or physical signs, the symptoms on which we so implicitly rely for a diagnosis of pneumonia in adult life ? Grisolle says that an exploration of the thoracic organs in pneumonia of the aged gives negative results in a majority of cases, and that we n base our opinion, 1st, on the extreme frequency of pneumoni . .ge ; 2d, that, of all the phlegmasia of advanced life, pueumou. one which is oftenest latent ; 3d, that, of all acute diseases in ol monia produces the high* tration. So, when an old person has a chill, followed by febrile movement and great prostration, and when the superficial ami splanchnic portions of the economy (other than thoracic) do not account for it • be diagnosed, even though all its (adult) diftgno A few practical hints as to the means of diagm their place here. The characteristic ex] e obtained on violent couu after several swallows of fluid have been taken. On causing the patient to cough and expire violently, tion, and tubular breathing "When there is no cough, rep it and dyspnoea also. Senile pneumonia may be confounded with capillary : and pleurisy. In both capillary bronchitis and senile pnenmoni - amuco- itant or subcrepitant rale ; but in pneumoi.. eumseribed to a - three or four inches in diameter, while in capillary bcond and heard best over th< When both lungs are i in pneumonia, while they are simultaneous in capillary bronchitis. There is dulness, or at least a diminution • sonance in pneu- monia, whereas an exaggerate bronchitis. In pneumonia there may be bronchial breathing, wliile in C bronchitis the vesicular murmur is feeble — often al In pneumonia there is but one, the initiatory chill, while in capillary bron- chitis there are several slight attacks of chilliness daring The pulse in capillary bronchitis may run op to 140 or 150 in the ear while 120 is about the limit of the pneumonic pall The temperature is always higher in ueumonia than in capillary bronchitis. Cyanosis is a marked and mptom of capillary bron- chitis, while it occurs only late in pneumoni.. erunner of death. Finally, a microscopic examination of t : -will THE DISEASES OF OLD AGE. 207 decide as to the condition of the alveoli, and whether pneumonia is or is not jjresent. A pleurisy with effusion sufficiently extensive to cause dulness would cause bulging of the intercostal spaces, with more or less displacement of the heart or liver, whereas these never occur in pneumonia. Again, the percussion-note would be flat over a large extent of sur- face in pleurisy, while a pneumonic spot would be evidenced by localized dulness over a small extent of surface. Besides, the line of flatness changes with the position of the patient in pleurisy, and is, of course, always sta- tionary in pneumonia. There is usually absence of vocal fremitus in pleurisy, while in pneumonia it may be increased, or at least normal. The respirations are " catching " in pleurisy, and panting in pneumonia. If bronchial breathing exist with a pleurisy, it is not as sharp, denned, and tubular in character as iu pneumonia, but rather subdued and diffused. Increased voice-sounds, bronchophony and cegophony are present in pneu- monia, while the voice-sounds are feeble over the pleurisy. A chill, when it introduces a pleurisy, is very slight, often absent ; a pa- tient with pneumonia generally gives a history of a distinct, often a severe chill. The temperature in pleurisy is two, three, or more degrees lower than in pneumonia. The face is flushed in pneumonia, while in pleurisy it is pale and anxious. The pain in pleurisy is sharp and stitch-like in character, located at the nipple of the affected side, while in pneumonia it is often absent, and when present is dull, diffused, and referred to various remote regions, all of which have been mentioned. It may be added here that the diagnosis of a pleuro-pneumonia is made upon a combination of the chief signs of senile pleurisy and pneumonia. Prognosis. — This is always grave, and the greater the age of the patient the less are the probabilities of recovery. Statistics do not give pneumonia its proper place among fatal diseases of old age. I believe it to be the most fatal of all the acute diseases at this period of life, for the number of autopsies that have been made in cases of "sudden death," in individuals of advanced years who have had "low" fever, "nervous" fevers, etc., exhibit in the vast majority of cases rector gray hepatization (of greater or lesser extent) that was not suspected during life. Many of the most reliable modem authorities — those who have had the largest experience in the hospital practice of the aged — state that nearly nine-tenths of those over sixty-live die of pneumonia. When pneumonia is single and confined to the lower lobes, the prog- nosis is much better than when it has its seat at the apices of the lungs. The prognosis is also more favorable when delirium is absent and the pulse is not irregular or intermittent. When the pulse-rate does not ex- ceed 110 or 120, and when the temperature-range is not above 103°, the prognosis is favorable. Thick, creamy sputa are very favorable signs. Prune-juice expectoration, the presence of any complication, extreme dyspnoea, excessive prostration, a sallow face, all these are very unfavorable signs. It is difficult to establish the average duration, but, in general, a prim- ary adynamic pneumonia lasts from six to ten days ; in fatal cases the sev- enth day is rarely passed. The first stage rapidly passes into the second, perhaps m four or six hours. 208 CLLNICAL LECTURES OX The stage of purulent infiltration, if it occurs, is reached very frequently before the third day, and in some instances within thirty-six or forty-eight hours from the onset. Pneumonia may be complicated by pulmonary oedema. Bright heart disease may have pre-existed, and thus act as complication results from cardiac failure, from asthenia, or from coniplicatio: Treatment. — The therapeutics of pneumonia in advanced life is very dif- ferent from that of adult life : often the third stage is reached before the aged patient consults you. Never bleed in senile pneumonia. In the Salpetriere it seems that an emetic, when not especially co indicated, was usually given in the fir <>nia. Tartar emetic is never 1 pneumonia. The physicians of the Mbntpelier General Ho spi t al regard ipeoacn as an heroic remedy in senile pneumi English physician & potash as efficacious : mans prefer hydrocblorate of ammoi Drastic pur- ment of senile pneumonia. The most important tiling to sustain the L antipyretics are rarely D Alcoholic stimulants and concentrated fluid nui liances in the treatment of this judicious use of stimulants arc all that are required ID t Iron and quinine may be employed in mod - the sustaining plan of treatment In typhoid, asthenic pneumoni i of q^uinu e ad- ministered with benefit; and the diarrhoea occurring with typhoid pneu- monia must be promptly checked by THE DISEASES OF OLD AGE. 209 LECTUKE XXIV. SENILE CHRONIC CATARRH OF THE BRONCHI. Summary. —Morbid Anatomy— Etiology— Symptoms— Differential Diagnosis— Prog- nosis — Treatment. Gentlemen :— Chronic bronchial catarrh is a very constant attendant of old age. It sometimes receives the name of " the old man's winter catarrh," one of its chief characteristics being its tendency to recurrence, the attacks increasing in severity and duration with each return of cold weather, until the individual is rarely free from it. It may be chronic from the onset, commg on late in life ; or it may be the sequela of acute attacks occurring in adult life or early manhood. Morbid anatomy. — Senile bronchial catarrh may have its seat in any por- tion of the bronchial tubes ; thus, it may be limited to the larger bronchi, or it may extend into the capillary tubes. Its anatomical changes are the same, whether it has its seat in the larger or smaller tubes. Usually the inflamed membrane has a gray or slaty blue color. The changes begin, primarily, in the mucous tissue, and subsequently involve the entire bronchial wall. Numerous small elevations and depressions are to be found upon it, often giving it a velvety look and feel. Occasionally it is of a deep brownish red color, and has a well-marked whitish look throughout the whole extent of the tract. Not infrequently the membrane is atrophied instead of hypertrophied, and it is then very thin, presenting neither fibrous nor cartilaginous tissue ; but, in either case the vessels are dilated — often tortuous. Vegetations, appearing as small, papillary elevations, may also occur. The bronchial glands are usually more or less enlarged, their mouths standing wide open and gaping. Two colored zones surround the gland, one around the centre, the other around the base. The process results in weakening of the walls, so that the violent and prolonged fits of coughing to which the individual is subjected cause dilatation at certain points. This dilatation, or bronchiectasis, is occasionally uniform — oftener, however, there is sacculation. The sacs, or ampullse, may attain the size of a hen's egg, and, when several are agglomerated, they resemble greatly a tuberculous excavation. The siu-rounding tissue always shows the characteristics of a jwi-bronchitis, all the changes being best marked at the periphery of the lung. Other portions of the tubes become narrowed, and so alternate stenosis and dilatation are very common conditions. The membrane may be covered with a thick, viscid layer of yellow, puriform material, or again (catarrh sec), a semi-transparent, glairy, mu- coid matter may cover, in a thin layer, the affected portions — the micro- scope revealing numerous pus-cells and columnar epithelium. The submucous coat exhibits an increase in connective tissue, and when 14 210 CLINICAL LECTUEES ON this increase involves the pulmonary parenchyma, we may have induration of the lung as the result. Just here it may be mentioned that the process resulting in fibrous induration may extend from without inward, i.e., from the pleura ; but it generally results from the inhalation of irritants, giving rise to a condition called "stone-cutter's phthisis." Accumulations of cheesy matter are occasionally found at points scat- tered irregularly throughout the bronchial tract, oftenest back of those localities where stenosis is marked. Again, degeneration, or decomposition of the secretions may result in ulceration, and thus a focus for gangrene of the lung is sometimes establ: The ulcers are usually tit the posterior portion of the t . rarely ex- tend deeper than the cellular tissue which connects the mucous membrane to the parts beneath. When, however, tb may occur into the oesophagus, I the pulmonary parent-]] Q abscesses may be excited by the perforation of a bronchial d the lun_ stance, or else inflammation ma] soli You very frequently find emphysema d< continued bronchitis, although under sue; will rarely be absenl ; and from wha: logical (senile) changes, it . most common pulmonary ] That ulceration which I with in • ease — the diffu-- Alicolar — may occur in though it is one of the rarest aocompanii irrh. The cartilaginous structures of the air-pass:. -jes sometimes suffer fication. In very old subje. I ns of ti. may become changed into os>« cavities of the bronchi — running through t" the bronchial cartilages ma\ brittle as to break or, during lite they may extend into the cavit iT, and be expectorated. Tubcr.lt ft] are Dot i' ssemi- nated throughout the lung ; such cases are more numerous the more ad- vanced th. Etiology. — Age is a n imposing cause of ehr< : chial catarrh. Vice of constitution LB under this head, stands g( nit, then rheum -eases, such as chronic i When the skin diaeaaei disappear, the bronchitis makes its appearance. Syphilis, chronic Bright 's disease, and chronic alcoholismus likewise predispose to this affection. Exposure to sudden changes of temperature — and thus a « •• climate, bad hygiene, overcrowding, poor ventilation, ai Q un- known atmospheric conditio:. c a o aea to bronchial catarrh. Organic diseases, such as reside in I mechanical and easily comprehended ma] the bronchial mucous membrane, and subsequently a state of d catarrh. Finally, it is to be remembered thai old persons exhibit a strong tendency to bronchial catarrh, even when the more marked p: and exciting eansi - lent Symptoms. — In the declining | THE DISEASES OE OLD AGE. 211 than to find, during the winter months, a cough and expectoration which the patient avers he has had " on and off" for years. It may not materially interfere either with his general health, but it is nevertheless " trouble- some," generally abating or entirely disappearing in the spring and sum- mer months. A moist, cold atmosphere or unusual changes in diet aggravate it, and sudden exposure is very certain to bring about what may be called an acute attack, or what the individual calls a "spell." Going upstairs pain- fully increases the shortness of breath, and there is a general feeling of tightness or fulness across the chest. There are no febrile symptoms ; but more or less dyspnoea and wheez- ing are constantly present, the shortness of breath oftentimes simulating an asthmatic attack. The simplest form, the one in which the larger tubes alone are involved, is where a moderately severe fit of coughing, usually occurring in the morning, is followed or attended by the expectoration of a yellow, yellow- green, or grayish mucus, which soon after becomes white. In some cases it is glairy in character, and in nearly all a microscopic examination shows it to be made up of pus-cells and mucus, with, perhaps, 9k few epithelial cells. The expectoration is oftenest nummular, although it occasionally runs together, and when very viscid is of an irregular, ragged, round shape, floating in a turbid, gray mucus. The name pttuitoua catarrh has been applied to chronic bronchitis when the sputum resembles the white of an egg mixed with water, and is ropy, clear, and gelatinous ; again, when with considerable coughing only a ball of pearl-gray, semi-transparent mucus is expectorated, it has been denominated "dry " catarrh — of course a misnomer. In this form the sputa are generally tasteless or slightly saline, or of a sickly sweetness and without odor. In the enfeebled and intemperate there is a form of chronic bronchitis where there is loss of flesh, and where night-sweats occasionally occur. This is marked by violent fits of coughing, followed by the expectoration of a gray, viscid, tenacious muco-purulent mass, which sometimes is watery, but which soon regains its muco-purulent character. The odor is sweetish, as a rule, but may often be slightly fetid ; it is never odorless. The amount varies ; but the average quantity is about a pint a day. During one of the paroxysms of coughing the effort to dislodge the mucus is often so strenuous that vomiting sets in, and the contents of the bronchi and stomach are ejected simultaneously. The expectoration contains, besides pus and mucus, epithelial cells in comparative abundance, albuminous matter, and now and then small por- tions of bronchial tissue. In this class of cases there is slight dilatation of the tubes and a small amount of attendant induration, but to a less extent than occurs in what Avill later be described as bronchorrhoea. Chronic bronchitis frequently occurs with gout, spasmodic asthma, and emphysema. (In the latter case the emphysema is the primary pathological condition.) In these cases the cough is violent, prolonged, and paroxysmal. For a time it seems as though the patient could not regain his breath ; his face becomes red, then livid ; the veins swell ; the eyes are suffused ; the head seems as if bursting, so that the patient clasps it in both hands ; the mouth 212 CLINICAL LECTURES OX is opened in a sort of gasp ; the jugulars are swollen ; and vomiting is often the result of the diaphragmatic pressure ; finally, a small, rounded pearl of tenacious mucus is expectorated, the patient takes a deep breath, and though immensely relieved, is weakened by the " fit," and is exhausted for some time after. Bronchorrhcea, also called "pituitous flux" and "bronchial flux usually associated with heart disease, and is marked by violent fits of cough- ing — less intense, however, than in the last-named variety ; and the expec- toration, often a pint at a time, of a glairy, colorless, transparent mucus, with froth at the top, looks precisely like the white of an egg in WSJ Two or three pounds may be discharged in two hours ; some; large quantities are, as the patients say, vomited up of a mornii is, at times, the ejection of the fluid. I cases. This form, frequently accompanying cardi if very apt to cause grave symptoms when the patient is expoi ulden changes in temperature ; or, especially, to strong winds ; and it is liable to merge into, or be accompanied by, pulmonary i Extreme fetor of the sputa is generally aat excitement; and it may be ral rule. t<> which, there are many exceptions, that Cetid I i with bronchiectasis. The sputa arc dbundm lor, and. in ra in the form of the smaller tu Occasionally there ifl a slight blood-tinge i:i ti. indicates the existence of superficial ulceration : aometu tion becomes brownish and find, the iniCTOSi pus-globules mingled with Catty granules, crystals of (jar in. Mixed with water, the pus readily it lit- tle mucin is present : and the solid parts <»f I of the containing vessel, tl • whitish, cheesy plugs intermingled. Physical sir always aggravated by exercise, motion, i Somel chest presents a more concave shape thin normal. Palpatio)! may reveal an in and dilatation of the bronchial tub. - fremitus is local. If dilatation of the air-tul uiitus will be diminished. Percussion. — There is a loss in the palmed marked cases. When emphysema exists with bronchitis (and ti the percussion-note will be somewhat tympanitic in el. Auscultation. — Feeble respiration bronchitis in the aged. The variety of adventitious sounds heard di respiration is, perhaps, greater than in any other pulm -ease. The respiration is harsh in character, oft. cular quality, but not tubular ; it also lias a peeui. When the tubes are narrowed, and when pitched, hissing, and sibilant 1. couth: bronchi. A sonorous, cooing sound ha- In the larger tubes, where also are produced large gurgling sounds that result from the DUl bubbles. THE DISEASES OF OLD AGE. 213 Similar conditions in the smaller bronchial tubes produce sibilant and subcrepitant rales. Since the bronchi of both lungs are affected at the same time, all varie- ties of dry and moist rales can be heard at different portions of the chest ; a sonorous is very near to a sibilant rale, and not far off is a subcrepitant or muco-crepitating rale. After a copious expectoration, the moist rales may wholly disappear for a time, and the auscultatory sounds vary greatly at different examina- tions. The sonorous and sibilant rales often completely mask the finer sounds. Fine sounds, like the musical notes from miniature organ -pipes, palpable to the patient himself, are frequently heard. When emphysema coexists, the expirations are prolonged and of a low pitch, and dyspnoea is much more marked. Bronchiectasis is evidenced at times by well-marked gurgling, the gur- gles being of large size, and most abundant at the lower portion of the lung. Finally, in long standing chronic bronchitis there will usually be some displacement of the heart downward, on account of the accompanying em- physema. Differential diagnosis. — Senile bronchitis is very often mistaken for senile phthisis. In phthisis there will be — when occurring with such symptoms as are common to chronic bronchitis — more or less retraction of the chest- walls ; while in bronchitis the chest is more frequently convex or bulging. Percussion in phthisis gives well-marked loss of resonance at the apex of the chest, which never occurs in bronchitis. Auscultation in phthisis may reveal a cog-wheeled or jerky respiratory murmur, a prolonged high-pitched expiratory sound, or the respiratory murmur may be completely tubular in character. These signs are not present in chronic bronchitis ; and if the expiration is prolonged, it is of low pitch. In advanced phthisis the dulness becomes wooden over the affected lung, there is amphoric or " cracked-pot " resonance on percussion, and on aus- cultation, cavernous or amphoric breathing with the metallic tinkle may be heard. These signs of a cavity are sometimes present in bronchiectasis, when it will be impossible to make a differential diagnosis ; in fact, such a form of chronic bronchitis may be regarded as bronchial phthisis. In all doubtful cases the history of the disease is important, and where the physical signs leave you in doubt, the presence or absence of fever, the character of the expectoration, and the amount of emaciation will decide the question. Prognosis.— Next to pneumonia, bronchitis is the most fatal disease of old age— some place it at the head of the list, but reasons have been given (see Etiology of Pneumonia) for questioning this statement. The duration of senile chronic bronchitis varies very greatly ; there are many cases where the old man's winter-cough has existed for twenty years. It may be relieved, but not cured ; the elements that oppose or favor re- covery are the following. The older the patient, the longer he has had the disease, the more feeble his condition, the more marked the predisposition to bronchial affections, the less are his chances of permanent relief or of partial recover}'. 214 CLINICAL LECTURES ON Again, a fetid expectoration, which is constant or increasing in amount, is an unfavorable sign ; as are also evidences of bronchiectasis or emphy- sema. Gout predisposes to acute attacks and gives permanency to the changes in the bronchial tubes. Emphysema and bronchiectasis predispose to pneumonia and pulmonary oedema. Hepatic congestion, abdominal dropsy and general anasarca are frequent attendants of chronic bronchitis ; seventy-five per cent, of such cases are com- plicated by a small, granular kidney. Intestinal catarrh is often a complication of chronic bronchitis, the chief signs being pain at the scrobiculus cordis, pain in the stomach, a sense of constant gnawing, a capricious appetite, indigestion, and flatulence. The liver is almost always simultaneously engorged in these cases. Death, in senile bronchitis, may result from pneumonia, gangrene, or oedema of the lungs, or from the renal, and rarely from the gastro-intestinal complications. Treatment. — A careful study of each individual case is important for the successful treatment of chronic bronchitis ; indiscriminate routine treat- ment, or the administration of favorite prescriptions, may do much more harm than good. A warm, dry climate, at a moderately high altitude, should be selected as a residence for this class of patients ; they should remain indoors as much as possible when the prevailing winds are east. Night air and cold are to be avoided. The sleeping-room should be well ventilated, and the temper- ature should be kept between 65° and 70 Fahr. Flannel should at all times be worn next the skin, and the cuta functions should be regularly stimulated by Turkish baths, rubbing, and moderate exercise. The diet must be simple and highly nutritious, for only in cases where the nutritive functions are active can any permanent relief be hoped for. The bowels must not be allowed to become constipated, and alcoholic stimu- lation must be regulated by the indications of each cae The most important thing to be accomplished initadtred treatment is the removal of its cause. When a weak heart is evidently its predisposing cause, digitalis may be administered. "When gout is prominent, colchicum, the iodide of potassium, and alkalies often produce marvellously beneficial efl\ im inhala- tions of hyoscyamus, coniuni, or stramonium are usually of great service in cases of gouty bronchitis. When syphilis is made out as the chief factor, iodide of potassium and the compound calomel pill will be found useful in connection with the iodine-spray inhalations. When there is amemia, which is very apt to be present in aged fen: cod-liver oil, iron, and moderate exercise in the open air, will be found of the greatest service ; while moderate stimulation, combined with qiiinine and strychnia, will sometimes give marked relief. When chronic skin discuses alternate with a bronchitu and sul- phate of zinc are to be administered for a long period. In emphysematous patients, iodide of potash, dilute nitric acid, and the ethereal extract of the acetate of iron, must be given daily for a long period. The rule m that a general tonic plan should be followed in all cases. In bronchorrho?a, and when the amount of secretion ipor THE DISEASES OF OLD AGE. 215 inhalations of naphtha, creosote, balsams, copaiba, or ammonium chloride often have the effect of checking or diminishing it. When a severe attack of bronchorrhoea comes on, a hot-air or vapor bath may be given in connection with sedatives or stimulants, according to indications. Dry cupping may be occasionally employed in such cases with benefit. When there is evidently a lack of power to expectorate, ammoniacal preparations, squills, senega, and the resins frequently afford prompt re- lief. "When a large accumulation takes place in the bronchi, do not hesi- tate to administer an emetic of sulphate of zinc. When the cough is so constant and harassing that it interferes with sleep, opium and cannabis indica may be given for relief. Local treatment consists in the application of dry cups, sinapisms, blis- ters, or stimulating liniments to the chest. Croton-oil liniment is most frequently used. Any of these measures may be employed, when they have been found to afford relief. Bloodletting is always contraindicated. Hepatic and gastric complications are best relieved by an occasional mercurial purge. 216 CLINICAL LECTURES ON LECTURE XXV. ASTHMA. Summary. — Nature — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treat- ment. Gentlemen : — Asthma stands next to bronchitis in the list of trouble- some affections of the respiratory apparatus in old age. It is now regarded as a disease of purely nervous origin. It has no special morbid anatomy. Tonic muscular spasm, or contraction of the circular muscular fibres of the bronchial tubes, is the essential element of an asthmatic paroxysm ; and their consequent narrowing, as evidenced by unmistakable physical signs, is a mechanical result. An analogue of this is found in spasmodic stricture after a gonorrhoea ; for a bronchitis is known to be the exciting cause in many cases of asthma. The bronchial membrane is first vascular, then occur certain catarrhal processes with which you are acquainted, and sub- sequently, through reflex nervous irritation, there is spasm of the bronchi, which is asthma. Etiology. — The causes may be divided, for convenience, into primary and secondary ; meaning thereby that one class affects directly the air-tubes, the other some organ or part remote from the respiratory apparatus. When the asthmatic tendency is present, there are a multitude of arti- cles which cause its development, such as smoke, dust, a fog, emanations from stables, hay, roses, burning sulphur matches, sealing-wax, the odor of horses, cats, and other animals — any of these may be sufficient to bring on a paroxysm of asthma. In some a neighborhood where filth prevails is one where their asthma is best, in others the approach to such a place brings on an attack. The same is true of dry air and moist air, of high lands and low lands, the mountain and the seashore. Some asthmatics cannot sleep or be free from asthma except in certain parts of the house ; and. again, the na- tive place of some patients is the only spot where they enjoy immunity from the disease, while others can never be free from it at home. These idiosyncrasies are strongest in advanced life, and are by no means im- aginary ; for, to witness the suffering of certain old persons when they dis- regard their well-known individual idiosyneracies, will be enough to show how real all these causes are, and at the same time show how powerfr. vous influences are in producing asthmatic paroxysms. Asthmatic attacks may be excited by the ingestion of certain artie: food ; this is the "peptic " asthma of some authors. The peripheral pneu- mogastric filaments in the stomach's wall probably suffer irritation in cases, and thus secondarily induce sp-sin in the parts supplied by tin ramifications of this nerve. THE DISEASES OE OLD AGE. 217 Broucliial catarrh is probably the most frequent of all the secondary causes of asthma in the aged. The tendency to asthma is often latent un- til a general bronchial catarrh is developed. Heart disease, "cardiac" asthma is the least common of all. It is produced in the vast majority of cases in a purely mechanical manner : by causing a passive hyperemia of the bronchial mucous membrane. The retrocession of gout and rheumatism, the abrupt disappearance of chronic eruptions upon the skin, the stoppage of an habitual discharge — any of these may be followed by a paroxysm of asthma, and it may be from the latter cause that the drying up of old ulcers is capable of producing the malady. Sometimes aged asthmatics have applied at the hospital for irritating dressings to keep open old ulcers, so certain were they of the effects of their healing. Among comparatively rare causes are cold feet, a loaded rectum, an en- larged prostate gland, and organic diseases of the brain. Finally, there is sometimes a well-marked hereditary predisposition, and, again, no cause can be discovered to satisfactorily account for the asth- matic paroxysms. Synijrfoms. — The symptoms of asthma may be divided into those which are present during the attack and those of the interval. Prodromal symptoms are of rare occurrence in the aged ; but when they are present they consist of languor, drowsiness, and depression, or the opposite condition of extreme lightness of spirits. There is very fre- quently a large quantity of " hysterical " urine passed some hours before the attack ; indeed, all the prodromata of asthma are eminently nervous in character. The attack proper — whether premonitory symptoms have or have not preceded it — usually begins with a sense of constriction across the chest, aud the peculiar paroxysmal dyspnoea. When, as is common in old age, dyspnoea is habitual, there is a sense of suffocation, and the patient begins to wheeze, cough, and perhaps has a fit of sneezing attended by running at the nose. There are anorexia and flatulent distention of the abdomen, with wheezing and increasing d}'spncea ; these may continue for a day or more. Again, there are no warning symptoms at all, and the attack comes on suddenly and unexpectedly. Early morning — from two to four o'clock — is the usual time for an asthmatic to be waked out of sleep by difficulties of breathing. Dyspnoea increases and becomes suddenly or gradually intense, so much so that it seems sometimes as if the patient could not live ; every muscle is called into play that aids in enlarging the chest, and all possible positions are as- sumed. The aged patient rushes to and opens the window to get air. The shoulders are elevated and brought forward. The face is pale or dusky, the features are altered, the mouth is wide open, the nostrils dilated, the veins in the neck and forehead are turgid, and the sufferer feels as if death were impending. Though he is in a dripping perspiration, the extremities — the lower especially — are cold ; the pulse is small, rapid, and thready. If expectoration have existed, it ceases in the acme of the paroxysm, and not until this is resumed will the fit end, not because the voiding of the collected mucus relieves the paroxysm, but because, when the bronchial spasm passes off, expectoration follows. 218 CLINICAL LECTURES ON Even when the attack begins " dry " there is always expectoration at the end, the result (not the cause) of the spasm. True asthmatic sputa consist of grayish pearls of mucus, like tapioca, and are usually free from either pus or watery material. So intense may be the paroxysm that streaks of blood appear in the sputa ; and in some (rare) cases, this amounts to actual hemorrhage. There is no rule as to the duration of one of these paroxysms. They sometimes continue for half an hour. I have known a paroxysm of asthma to continue for seventy-two hours in an old man of eighty. Less violent attacks may continue without remission for five or six days ; again, each attack is made up of several shorter ones, the intensity of which varies greatly in different cases. The longer the attacks the slower and less abrupt the departure, and the more profuse the sputa. After an attack the patient is often reduced in strength and exhausted, has aching limbs, depression of spirits, and a feeling of " soreness" in all the respiratory muscles. In " cardiac " asthma, the symptoms are very much aggravated, and the patient being usually conscious of the heart-lesion, has not even hope left in the midst of his sufferings, and often prays for death to come and end them ; after an attack of this kind, convalescence is very slow. The character of different attacks in the same individual varies. If at first they are violent and exhausting, later they may assume a milder form, and lose somewhat their periodical character and run into each other, so that the individual is never entirely free from paroxysmal dyspnoea. There is always at first a periodicity to asthmatic attacks, the intc a between the paroxysms varying in length. As a rule, the longer the individual has been subject to asthma the shorter the interval between the attacks ; this is especially true in the verv old. It may be mentioned here that no physical signs are present, except during the paroxysm. Some have stated that the urine exhibits a remarkable diminution in chloride of sodium and urea immediately after an attack, while later resume their normal standard. Usually, after an asthmatic attack has passed, most asthmatics are com- paratively well ; the patient feels certain he will be free, for a certain time at least, from another, and mean while can enjoy good health. Physical si>s. — During the paroxj shows labored breath- ing, but no increase in the number of the respirations. Inspiration is shortened, while expiration, though effected by abrupt and violent efforts, is longer than normal. The muscles of the neck are immovable and the vessels are distended. Palpation gives normal vocal fremitus. Peivussion elicits slightly exaggerated resonance. It is auscultatio)} that enables us, if doubt could exist in well-niarked asthma, to obtain distinctive results. The inspiratory murmur is heard very faintly or is wholly absent ; this is especially the case in very old sub- jects. No vesicular quality is present, and the expiration-sound i- longed and low-pitched. Sibilant and sonorous rales, high-pitched, hissing, wheezing and squeak- ing in character, are heard over the whole chest, and especially over and between the scapula? in the very old. Often these dry sounds have a musical character. When moist sounds THE DISEASES OF OLD AGE. 219 are heard, it is either because chronic bronchitis complicates the asthma, or, as the paroxysm is drawing to its close, mucus collects in the tubes. Asth- matic sounds are oftentimes heard at some distance away from the sufferer. The number and kind of sounds heard during the beginning of a severe asthmatic attack cannot be enumerated ; they are constantly chang- ing their locality, and also their nature in the same locality. In some cases— the tubes perhaps not being all affected, or equally so — the respiratory murmur is heard in patches ; it is apt to be exaggerated in these spots. All the sounds are loudest during expiration, and in some instances they may even be limited to that period. During the interval between the paroxysms there are no abnormal sounds. Differential Diagnosis. — Asthma may be confounded with laryngeal .spasm, angina pectoris, pulmonary cedema, bronchitis, emphysema, and pericarditis with effusion. I. — Spasm of the glottis is attended with voice-changes never present in asthma ; and, besides, there are the physical signs of asthma. II. — Angina pectoris is attended by pain of a lancinating, cutting, or stabbing character, while asthma is, as its name indicates, a gasping for breath. Angina pectoris is accompanied by no physical signs of pulmonary abnormalities, while the patient himself usually attributes everything to the heart. III. — In pulmonary oedema there is dulness on percussion over the oadema, while in asthma the chest is extra-resonant. The rales in cedema are liquid bubbling rales, while asthmatic sounds are dry. Pulmonary oedema is early accompanied by profuse watery expectora- tion, while after an asthmatic fit small pearls of gray mucus may be expec- torated. TV. — Bronchitis is of slower advent than asthma, and is accompanied by the distinctive moist redes, while asthma is marked by manj r and various dry sounds, and is very sudden in its advent. The respirations in bronchitis are always more rapid than in asthma. The character of the sputa will also aid in the diagnosis, for it is usually purulent in the former, and never so in asthma. V. — Emphysema is never wholly unaccompanied by dyspnoea, while asthmatic patients do enjoy intervals of immunity. Emphysema is accompanied by its characteristic percussion-note, vesi- culotympanitic in character, and this is never present in uncomplicated asthma. Prolonged low-pitched expirations exist, usually in emphysema ; and in asthma, the duration, if prolonged, is never low-pitched. Finally, the aspect of the patient, the barrel-chest, and the change in the position of the heart which accompanies emphysema, will enable you to make a diagnosis. VI. — Perhaps one of the diseases most likely to be mistaken for asthma when it occurs in old age, is latent pericarditis with effusion. It may be, and often is, accompanied by dyspnoea, which is spasmodic in character, and pain may be wholly absent ; hence the mistake in the diagnosis. The chief signs by which pericarditis is to be recognized, are feebleness and often irregularity of the pulse, faintness, diminished cardiac impulse, obscure heart-sounds and increase in the precordial dulness ; and, nega- tively, in pericarditis there will be no rales, no history of previous asth- matic attack — indeed, no pulmonary symptoms whatever. 220 CLINICAL LECTUEES ON Prognosis. — Senile asthmatics are generally long-lived ; a paroxysm of asthma rarely terminates fatally, and when death occurs during an attack, it is most generally from pulmonary oedema or congestion. It is the attendant circumstances that have to do with the establishing our prognosis ; and also the fact that severe and prolonged attacks may bring on emphysema of the lungs and right cardiac hypertrophy., and dila- tation incident to obstruction in the pulmonary capillaries during these paroxysms. When organic diseases exist, as for example, a chronic bronchitis, then the disease must be looked upon as incurable ; and the more advanced the age, the more unfavorable is the prognosis ; hence, in this class of patients the disease may be put down as inc. arable. "When no abnormal lung- or heart-sounds are heard during the intervals between the attacks, the outlook is better than when the reverse is the case. Asthma may be complicated by cln*onic bronchitis, emphysema, bron- chiectasis, pulmonary oedema and congestion, cardiac dilatation and hyper- trophy. Death, if it occurs, usually results from the pulmonary complica- tions. Treatment. — In the treatment of asthma, two things are to be consid- ered : how we may relieve the paroxysms, and how we may prevent their recurrence. In other words, the treatment is to be palliative rather than curative. "When a patient has a paroxysm of asthma, the first thing to be doi to remove the exciting cause when it can be reached. When the st< has been overloaded, an emetic should be given ; when the rectum is over- filled, an enema should be administered : when smoke, dust, or the emana- tion from anything which induces the tit. these should be removed, or the patient withdrawn immediately from their influence. It is the same with localities and emotions, or nervous impressions. The removal of the cause may alone bring about speedy relief. But when this is not the c~z% or when no ca le, then certain remedial measures may be employed. The room in which this class of invalids spend most of their time should be large and well-ventilated, the curtains should be removed, and all ob- struction to the ingress oi sunlight and fresh, cool sir The idiosyncrasies of old people suffering (hit should 1 The next step is to select those remedies best adapted to the esse, and the choice depends much upon the individual's experience and individual constitutional idiosyncrasies; most asthmatic patients know what Lb suited to their case. The remedies may be divided into three classes : depretmnt*, wedai and stimulants. 1. Depressants, — The chief drugs in this class are antimony, ipe anha, lobelia, and tobacco. The object in the use of these is to com} relax the spasm, and whichever drug is chosen it should be exhibited until the required effect is produced. Ipecacuanha may be given to produce nausea, and tobacco should be smoked until nausea and a feeling of faintness come on, when the attack oi asthma ceases. Mild tobacco should be used by old people and vomiting ought never to be induced by its use. 2. Sedatives act either locally on the pulmonary nervous apparatuf generally upon the whole nervous system. THE DISEASES OF OLD AGE. 221 Those of the greatest value in asthma are chloroform, opium, stramo- nium, ether, cannabis indica, hyoscyamus, and the fumes of nitre-paper. There is, perhaps, no agent that so promptly relieves as chloroform, and this, too, when all others have failed. Great care should be exercised in giving chloroform to the aged, and the condition of the heart must always be carefully considered. The relief is in any case but temporary. Ether is pleasanter than chloroform, both to inhale and in its results : a combination of the two will in some cases be fourd more effective than either alone. Hypodermics of morphia, when combined with atropine, act well in many cases ; this combination acts much more powerfully than either drug alone. Nitre-paper, one of the oldest and best known remedies for asthma, is prepared by dipping filter- or blotting-paper in a saturated solution of salt- petre. The fumes of the nitre-paper give no relief when bronchitis ac- companies the asthma, and as these two maladies coexist so often in old age, it is seldom of much service in senile asthma. When used, the room must be filled with the fumes from the burning- paper. Its action is not well understood. Stramonium leaves, when smoked, will in some bring about speedy re- lief, while in others no relief follows their use. Internally, in the form of extract, stramonium does not afford the same relief as when the dried leaves are smoked. The datura tat via is regarded by some as more efficacious than datura stramonium. Many old asthmatics will not go to bed until they have "had their stramonium pipe." It may be added here that the habitual use — in either sex — of tobacco seems to have a favorable influence, and in some cases gives complete relief. Conium, hyoscyamus, and belladonna sometimes afford relief, but much less certainly than the stramonium. They may be tried, however, in obsti- nate cases. The nitrite of amyl has not proved as successful as its physiological prop- erties would warrant us to expect. 3. Stimulants. — The two chief stimulants to be employed in the treatment of asthma are coffee and alcohol ; coffee is the most efficient, and should be taken upon the occurrence of the first symptoms of an asthmatic attack. It must be very strong and without milk. Two or three cups are sometimes necessary to ward off an attack. It should never be administered on a full stomach, for then it may excite or aid in inducing an attack. Alcohol is sometimes of great service in the treatment of asthma. It is of little importance what form of alcohol is employed, provided it is hot and strong ; in other words, it must be given as a " hot toddy." It must be given in sufficiently large doses to produce its intoxicating effects. As it is sometimes the only remedy that will relieve, and as larger doses are re- quired at each attack, there is danger that its use may become habitual. Asthmatic patients who are relieved by alcohol, as a general rule, have their paroxysms occurring during sleep, and as during sleep the nervous system is more depressed than during waking hours, these individuals are more susceptible to the exciting causes of the asthmatic fit when asleep than when awake. As in all nervous conditions the remedy which is first "the specific," so called, will later become useless, and then a new one must be tried, and so the changes may be rung on half a dozen drugs with success. Compressed air has not been found serviceable in the treatment of asthmatic attacks, and the inhalation of oxygen does not exercise any mark- edly beneficial influence. 222 CLINICAL LECTURES ON The treatment in the interval is essentially hygienic, although some state that, in cases whose cause is undiscoverable, the iodide of potassium not only prevents or delays the attacks, but even prevents their return. Again, when cutaneous disorders appear to irregularly alternate with asthma, the internal use of arsenic will be found of service. Quinine, five or ten grains a day, will sometimes prevent asthmatic par- oxysms, and when old asthmatics suspend it for even a short time, the par- oxysms may return with greater severity. One, if not the most important duty of the physician in treating senile asthma, is the regulation of the diet of the patient. Breakfast, at eight o'clock, should consist of half a pint of green tea, or of coffee, and a little cream and two ounces of yesterday's bread. Dinner, at one o'clock, two ounces of fresh beef or mutton (no fat), and the same quantity of well-boiled rice or stale bread ; and in about three hours after dinner half a pint of weak brandy and water, and as much toast-water as desired. No water is to be taken within one hour before dinner or supper, or until three hours after. Flannel should constantly be worn next to the skin, and the flesh-brush may always be employed with benefit. Moderate exercise only is allowable, and cold bathing of the chest must be prescribed with caution in old people. Remember that old asthmatics are always prone to cold feet ; hence, woollen socks are to be worn, and all chilling of the body carefully avoided. When tonics are indicated, iron and quinine will be found best for asthmatics of advanced life ; as to climate, experience is here the only ami the best guide. It may be said that all confirmed asthmatics are dyspeptic. It is there- fore important to study the idiosyncrasies of each individual case, in the interval between the paroxya THE DISEASES OF OLD AGE. 223 LECTUKE XXYI. ATHEROMA.— FATTY HEART. Summa ry. — Atheroma — Morbid Anatomy. Fatty Heart — Varieties — Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treatment. Gentlemen : — Before we commence the study of the diseases of the heart and blood-vessels in old age, I desire briefly to call your attention to the more important modifications which the heart and circulatory sys- tem undergo in advanced life. The heart of the aged differs in many respects from that of adult life. Contrary to what occurs in the other organs, it does not diminish in size or weight as age advances ; in very many cases it undergoes actual hyper- trophy. Indeed, it may be said to be physiological for the heart to exceed by one-twelfth its normal adult weight. Its average weight in males over sixty is eleven ounces — in females of the same age, nine and a half ounces. It is broader than in adult life, and the cardiac substance, in the majority of cases, is pigmented. Yet in emphysema, and in those very old people who seem " to shrivel up," the heart may be no larger than a base-ball, and somewhat resemble it in shape. The increased size and weight of the heart are due to progressive thick- ening of its walls ; the capacity of both the auricles and ventricles are in- creased ; and there is an enlargement of the auriculo-ventricular openings. The ratio of increase in the capacity of the right and left cavities is equal ; but the left ventricular walls increase in thickness much more than the right. This thickness of the left ventricle varies considerably with the place measured, since its thickness rapidly diminishes from base to apex ; at the latter point the endocardium and the tunica propria almost meet, so thin is the ventricular wall. The auriculo-ventricular orifices undergo a uniform enlargement ; but the aortic orifice enlarges much more rapidly and to a greater extent than the pulmonary, and some state that aortic insufficiency is physiological in old age. The valves are thickened, and so is the endocardium, either in points or throughout its entire extent. The ascending portion of the arch of the aorta is generally dilated to a considerable degree ; this is undoubtedly the result of the blood-current striking upon the aortic walls, whose elasticity is gradually diminishing. It may thus attain its double calibre, and the walls generally become much thicker in such cases. This thickening takes place in all the tunics of the artery. The loss in the elasticity of the aorta is due to connective-tissue in- crease and to fattv or to calcareous degeneration. 224 CLIXICAL LECTURES ON Again, in many old subjects there is minute injection of tlie aorta and pulmonary artery just as they leave the heart. The reflected portion of the pericardium is then quite lax, as is also the subcellular tissue ; and the arteries and veins therein are enlarged and tqrtuous. The veins in old age lose much of their elasticity, and increase in size and in the thickness of their walls ; all venous changes are most marked in the lower half of the body. The amount of blood is diminished in old age (senile anaemia), and nearly all the viscera are in an anaemic condition. It contains less solid constituents, especially red globules and albumen. It is clearer, more fluid, contains more cholesterin, and coagulates much more readily than in adult life, which accounts for the coolness of the extremities in old age ; at least this is one of its causes. At this jDoint it is important that I should say a few words concerning atheroma, for this is the great factor in the production of all senile patho- logical changes. Atheroma. — The term atheroma includes a pathological condition of the arteries which may be, and often is, a combination of chronic arteritis, fatty and calcareous degeneration. The earliest stages of atheroma are marked by an infiltration of cells into and beneath the inner coat of the vessel. These cells are leucocytes mingled with connective-tissue cells. This hyperplasia causes bulging of the tunica intinia toward the axis of the tube. At first the swelling is soft, and can be easily removed. Retrograde metamorphosis gradually occurs as a result of defective nutrition, the new cells undergo fatty degeneration, and a soft, yellow mass, called an "atheromatous / tia," results; or, the lining membrane rupturing, the pultaceous contents are swept into the circulatory torrent, and we then have the atltcr Again, when neither of these processes occurs, the liquid portion of the mass becomes absorbed, cholesterin is formed, and then in the deeper layers there is a debris of broken-down cells, cholesterin crystals, fat- ules, and some of the original fibrillated tissue, which, subsequently fying, beeomes a calcareous plate. A frequent change in old age consists in thickening of the inner coats of the vessel In the aorta, just above the aortic valves, you will see, in old :. white or yellow-white patches extending over a considerable space. These calcareous plates are friable, transparent, and inelastic, sometimes thickened at their irregular rims, and when the vessel is dilated in - and the plates are numerous, we have what has been called "senile arteritis deformans," In old age the arteries of the brain and heart are affected in an ah equal degree, as well as those of the chief glands. The same processes and the saine results occur in old age in the valves of the heart, which are sometimes markedly cribriform and rugated. In connection with atJieroma may be described the whit- the heart and pericardium, which are unimportant, except that they common in advanced life, and are not found at other perio They are usually on the anterior surface of the right ventricle, and \ in size from that of a pin's head to that of a two-cent piece. Tin very irregular in shape, and sometimes can be dissected off if brane. There are two theories concerning them — an inflammatory I non-inflammatory ; the former is the 1 1 and support*. THE DISEASES OF OLD AGE. 225 They occasionally occur on the pericardium, and are far more common in old men than women. The almost cartilaginous consistence which the vessels have, when atheroma is of long standing, may lead to sufficient retardation, or arrest, of the blood-current to cause arterial coagula ; and then gangrene of the extremities, fatty degeneration of the heart, or cerebral ramollissement may follow. This is sometimes called the "marasmic thrombosis," and there is, undoubtedly, a diminution in the influence exerted by the vaso- motor nerves upon the arteries. From this impediment may also come dilatation and tortuosity of the veins. In individuals in advanced life, it is rare not to find a chronic peri- arteritis accompanying the lesions of the heart and vessels which I have just described. And where the aortic arch gives origin to the great vas- cular trunks of the head and the upper extremit}-, rings of bone-like matter very often surround the orifice of the branch. Having considered the usual condition of the heart, vessels, and blood- mass in old age, and the lesions which constitute senile atheroma — that lesion which so often is followed by so many and terrible results — we are prepared to consider the modifications that occur in the heart and pulse in normal old age. Percussion. — The normal area of dulness in the adult, which, you re- member, is of a triangular shape, with the base immediately below the junction of the left third rib with the sternum, and the apex on a line of the cartilage of the sixth rib, is usually increased about half an inch in all directions in old age. The apex-beat is lower down, being, as a rule, three instead of two inches beneath the nipple, and is carried nearer the axillary line than in adult life. When the organ is overlapped by an adherent portion of the lung, or when there is emphysema, percussion may wholly fail to accurately map out the size of the heart, and to discover its exact dimensions. Auscultation. — As a rule, the heart-sounds may be said to be duller. The first sound, especially, seems in old age as if it were prolonged and muffled. A moderate aortic insufficiency is usually unaccompanied by any marked auscultatory symptom, but may give the same murmur and the same area of diffusion as in adult life. Pulsations in the veins. — It is stated by many writers that the tricuspid valves are normally in the aged slightly insufficient, and this is hence re- garded as a sort of safety-valve. Now, it has been said that the auriculo- ventricular orifices become larger in old age, and thus jugular pulsation, from both these causes combined, is a quite frequent occurrence iD old age. Now and then they are markedly distended, and you may notice a thrill. When aged subjects are excited, it is frequently the case that the veins above the clavicle present a marked undulatory movement, and this may be perceptible in the emaciated, even beyond the region of the neck. The pulse.— The heart's action in old age, although no less powerful than in adult life, is nevertheless accompanied by an impulse which is less visible. The number of pulsations in aged females is always greater than in males. As examples of extreme slowness of the pulse may be men- tioned the cases where the pulse in a man eighty-eight years old was twenty-nine, in a woman eighty-two, thirty-six ; and in a man eighty-nine, twenty. That such slow pulses are compatible with normal senile cardiac conditions, there can be no doubt. In old age, when no lesions are/ present, it is not uncommon for the 15 226 CLINICAL LECTURES ON heart to present irregularities both in the strength of its beats and in its rhythm. These two conditions may both occur in the same individual, or there may be only a loss of rhythm. It is a peculiar and interesting circumstance that when acute diseases occur in old people whose hearts are thus irregular, the rhythm and strength become, during the disease, perfectly normal, to change again when recovery occurs. There is no satisfactory explanation of this occur- rence. The pulse in advanced life is quite characteristic : it is, hard, wiry, and deficient in elasticity, so that its unvarying rigidity makes it an uncertain means of investigation. The radial artery shows the changes of age better than any other : as you slide the readily moving skin over the artery, the calcareous plates often give a sensation similar to that of passing the finger over a tube filled with shot. Failure to appreciate these arterial changes has undoubtedly led to many fatal bloodlettings in old age, for the older the subject the firmer and harder seems the arterial impulse. As I have already stated, it should always be the rule to count the pulse at the heart in old age. These are the more important changes in the heart and vessels in the aged. By keeping them constantly in mind, much of error may be avoided. The first cardiac disease that claims our attention is fattv heart. Fatty Heart. Fatty degeneration is the commonest degeneration in old age ; it is one of the prominent factors in what is denominated senile decay. Fatty degeneration may be either partial or general, and. as in adults, presents itself under two forma " Quoin's fatty heart " is a degeneration of the primitive muscular fibres, and is properly so denominated; while the deposit of fat in the areolar tissue of the heart, or the replacing of the connective tissue by fat, is in reality, fatty ii filtration. Morbid anatomy. — In advanced life, this degeneration is most often met with in the left ventricle near its apex ; next in order cornea the right tricle, and lastly, the right auricle and left auricle. The first change in this degenerative process is a loss of the nuclei of the primitive muscular fibres, with a simultaneous loss of their striated a] ance. Granules, completely filling the sarcolemma. make their appearance, and from having the look of albuminoid matter, change to fat-gramil. - oil-globules, rarely larger than a red blood-corpuscle ; they are generally ar- ranged in very nearly even rows, and at last absolutely till the sarcolemma. The normal size of the fibres remains unaltered and all the fibres are not affected to the same extent. Some have divided this degeneration into two forms : the granular and the fatty. But the former is more usually regarded as only d the latter. A heart which is the seat of this change is of a paler color than normal, more opaque, and its tissue is friable, breaking down with a soft, granular fracture ; there is a distinct loss of cohesion. The organ is usually r. in size (that is, the normal size for advanced life) : it may be hvjx rtrophied or dilated, the latter being the much more frequent condition. In some THE DISEASES OF OLD AGE. 227 very old people the discolored and flabby heart is noticeably diminished in size. When the degenerative process is partial, the heart will collapse when removed from the body, and exhibit a mottled appearance, the spots vary- ing in color from a drab, gray, or dirty brown hue. These opaque patches are unevenly distributed over the heart, and occur in the papillary muscles, the columns corneas, and especially in the fibres just under the endocardium. They are readily broken by pressure of the linger, and under the microscope will show large oil-globules and fat- granules, many of which have escaped into the adjacent tissue. On section the blade of the knife is covered with the fatty material, and the organ may leave oil-stains on paper. This partial softening is so common at this period of life, that some French writers call it senile softening. The coronary arteries may be obliterated, calcified, atheromatous, or normal ; there being no necessary relation between abnormalities of these vessels and fatty degeneration of the heart, except when it is secondary to muscular hypertrophy. In fatty infiltration there is merely an increase of fat in the areolar tissue. Strise of fat may be seen lying among the muscles, or so thickly is the heart encased in it, that it seems to be but a mass of fat. This accumulation is always most marked at the external surface of the organ, diminishing toward the endocardium. It may establish true fatty degeneration, or fatty metamorphosis, by its pressure, and thus an in/ra-stitial may become an inter-stitidl process. This is sometimes called senile obesity of the heart ; and you will usually find in the hearts of old people depositions which are quite exten- sive around the base of the ventricles, in the line of junction between them and the auricles, and at the origin of the large vessels. Along the course of the coronary vessels the fat is contained in oval or round cells whose average diameter is about one one-hundredth of an inch. This differs markedly from true fatty metamorphosis. Etiology. — Fatty heart is essentially a disease of old age, although it may occur at any age. The liability to it steadily increases with advancing years. Fatty infiltration, overgrowth, or senile obesity occurs usually in those who have an excessive development of adipose elsewhere. It is twice as frequent in the male as in the female, and the influence of heredity cannot be doubted ; there is, in a large number of old people, a constitutional ten- dency either inherited or acquired. Sedentary habits exert a marked in- fluence in developing, or aiding the development of fatty infiltration of the heart. Fatty heart often comes on not only with senile marasmus, but also with thot marasmus accompanying Bright's disease, gout, phthisis, cancer, and chronic alcoholismus. It is worthy of remark that fatty heart from such causes seldom reaches a point where it seriously interferes with its action. In old age a very frequent cause of cardiac degeneration is interference with the coronary vessels. Such interference may be due to atheroma and calcification of these vessels, to embolic obstruction, external compression, from pericardial thickening, or impaired recoil of the aorta from any cause whatever. Poisoning from phosphorus or phosphoric acid, and perhaps dis- ease of the cardiac ganglia may lead to this diseased condition of the heart. Finally, in some instances, the causes of true fatty degeneration or metamorphosis of the heart must be regarded as yet undetermined. Symptoms.— -The objective signs of fatty degeneration of the heart in old 228 CLINICAL LECTURES ON age are obscure. Indeed, some authors (Balfour among them) state that it cannot be recognized during life with certainty. Moderate fatty de- generation will go unrecognized, and sudden death may occur when there is no suspicion of its existence during life. The disease progresses slowly and gradually, and the symptoms vary in proportion to the extent of the process. The aged patient is incapable of attending to any business that requires the slightest physical exertion ; the muscular power is steadily diminished. The breathing is easily embarrassed, and tits of dyspncea and palpita- tion are easily induced, and during the paroxysms there may be acute pain and faintness, the attacks simulating those of angina pectoris, while tinni- tus aurium, giddiness, and other phenomena of a deranged cerebral circu- lation, are very common characteristics. During the parox}-sm the liver enlarges and the respiration becomes feeble and irregular, frequently sighing in character. Attacks of syncope, the result of cerebral anaemia, increase in frequency and severity as the disease progresses, and it is a peculiarity of fatty heart that the patient himself is aware, on a retrospective view, that there has been a steady and decided loss of muscular power. Independent of all ''anginal" attacks, you will now and then meet cases where pain is seated over the cardiac or sternal regions, or shoots down the arm during the greater part of the time ; it then becomes one of the most troublesome symptoms. The countenance is sallow, " pasty," or pale ; perhaps livid from venous stagnation; the extremities are cold, and, in a few cases, oedemaious. The tissues of the body are flabby and there are the usual evidences of arterial degeneration; arcus senilis is a valuable sign of this form of cardiac de- generation, being regarded by the older writers as nearly pathognomonic. In order that the arcus senilis shall be significant of cardiac degeneration, the ring must be well defined, rather yellowish in color, the remainder of the cornea being cloudy and opaque, a tinge of jaundice coexisting. Old people with fatty heart find their memory less retentive than in pre- vious years, and those about them notice a change in their disposition ; they are very apt to become morose, moody, irritable, and to have an ha- bitual depression of spirits. Derangements of the digestive organs, ano- rexia, and sometimes diarrluva and vomiting occur with senile fatty heart. The pulse is /critic, never strong, although it varies in force at dif times : at one time regular, at another irregular in both rhythm and force. The, irregularity is most apparent after sudden excitement or violent exer- tion. At times the pulse will beat very rapidly for a few moments, and then drop to thirty or forty per minute, becoming in such cases markedly ir- regular. The rule is that, in old age, fatty heart is accompanied by a slow, weak, and. irregular pulse. A. peculiar kind of dyspncea, the " Cheyne-Stokes dyspnoea," or M the as- cending and descending respiration," was formerly regarded as char istic of fatty degeneration of the heart This is not true, but it so fre- quently accompanies this disease that it is necessary to refer to it Cheyne, who first wrote about it nearly eighty years ago. thus describes it : ''For several days the patient's breathing was irregular : it would en- tirely ceaxe for a quarter of a minute, then it would become perceptible, though very slow. Then, by degrees, it became heaving and quick, and next would cease again. This revolution in the state of breathing occupied about a minute, during which there were about thirty i juration. '' THE DISEASES OF OLD AGE. 229 Physical signs. — Inspection. — The apex-beat is seen faintly and indis- tinctly ; in extreme cases it is invisible. On palpation the hand will either detect no movement whatever over the precordial space, or the movements will be only occasionally felt, and then but very feebly. The impulse resembles that imparted to the hand by an aneurismal tumor. When dilatation coexists, a tumbling, rolling motion will be noticed, but this is a sign of dilatation, not of fatty heart. Percussion may elicit dulness over an abnormally large area, but this is from "obesity" or "fatty overgrowth" of the heart, or from pre-existing dilatation, which is so frequently associated with this form of cardiac de- generation. Auscultation. — The first sound of the heart will be feeble or absent. When audible it is entirely valvular, and is followed by a comparatively long period of silence. It is a "toneless" sound, and is higher-pitched than is usual in old age. Indeed, the shortening of and rise in pitch in the first sound may cause it to closely resemble the second. The second sound is feeble, and less distinct than the first. Rarely will you have murmurs in senile fatty heart, whatever may be the anatomi- cal condition of the valves. Temporary absence of the first sound may occur in senile ancemia and in some acute diseases of advanced life ; but the sound will return when the anaemia disappears, or during convalescence from the disease. Thus, a con- tinued absence of the muscular elements of the first sound becomes one of the most important signs of fatty heart. Differential diagnosis. — Cardiac dilatation is most likely to be mis- taken for fatty heart, and, indeed, the two often coexist. In dilatation, percussion elicits a well-marked increase in the area of cardiac dulness ; while in simple fatty degeneration the outline of the heart is shown to be normal. The first sound in dilatation may be feeble, but it is never absent, a condition frequently met with in senile fatty degeneration. There are few, if any, of the cerebral symptoms in dilatation which so constantly attend a fatty heart. The Cheyne-Stokes respiration and the arcus senilis are prominent in fatty degeneration, and do not occur in dila- tation of the heart. Symptoms of pulmonic obstruction and congestion will rarely be absent in cases of dilatation which will be likely to be confounded with fatty heart, while such symptoms are exceedingly rare in cardiac degenerations. Prognosis. — The prognosis in fatty heart is bad ; it is incurable. The fatal issue may be delayed when the cause can be removed, as in cases of chronic alcoholismus ; some claim that a condition of fatty heart, accompanied by a like degeneration of the vessels, is not without its ad- vantages, since a feeble heart is thus adapted to a feeble arterial system. Fatty degeneration of the cardiac wall may exist for years, but life is always insecure ; it is the fact that sudden death may occur at any moment which renders the disease so formidable. These patients become more and more feeble until, finally, general dropsy sets in, and asthenia closes the scene ; or more frequently syncope, coma, or rupture of the heart, unexpectedly cause the fatal issue. Rupture of the heart has no well-defined symptoms, and is immediately fatal. Treatment. — Nothing can restore a heart in the advanced stage of fatty degeneration. The age of the patient, the feeble heart, the cachectic condi- tion, all demand a supporting and a tonic plan of treatment. Iron, strychnia, cod-liver oil, a generous but easily assimilated diet, a 230 CLLNTCAL LECTURES ON moderate allowance of some nutritious wine, as Burgundy, are the only means which we have for increasing and improving the tissue-making power. It is hardly necessary for me to say that when there is any palpable ex- isting cause, such as chronic alcoholismus, it must at once be removed. No violent exercise, no prolonged moderate exercise, no excitement can be tolerated by these patients without absolute harm. The patient must live the life of an invalid, and all hygienic measures must be strictly re- garded. The bowels must never become constipated, for straining at stool might cause rupture of the heart and death. Digitalis is of little service ; its administration, may, however, give tem- porary relief. In simple obesity of the heart, alkalies are believed to have a very favora- ble influence, and here the food must contain a minimum of hydrocarbons, and if an excessive amount of food has been taken, the amount must be restricted. Exercise may be allowed to a moderate degree, but our main reliance is on the diet. The attacks of syncope may be relieved by such stimulants as strong coffee and ether ; the nitrite of amyl relieves both the fits of dyspnoea and the suffocative oppression accompanying anginal pain. To relieve pain by narcotics is a dangerous procedure under these cir- cumstances ; hypodermics of morphia have been followed by instant death, as also have inhalations of chloroform ; ether is perhaps the least dan- gerous. The treatment is purely palliative, and the prolongation of life dejiends on the ability of the patient to so regulate his diet and surroundings, and to spend so much of his time in the oj>en air as his particular ms to require. THE DISEASES OF OLD AGE. 231 LECTURE XXVII. CEREBRAL HEMORRHAGE.— APOPLEXY. Summary.— Morbid Anatomy— Etiology— Symptoms— Differential Diagnosis— Progno- sis— Treatment— Cerebral Softening— Ramollissement— Morbid ° Anatomy— Eti- ology. Gentlemen : — By the term cerebral hemorrhage is understood an ex- travasation of blood within the cranial cavity. The term apoplexy, literally means the results produced by the extravasation of blood into brain-tissue ; but it is often applied to those extravasations which are serous, as well as to those which are sanguineous. Hemorrhages, the result of traumatism, are not included under the head of apoplexy. Morbid anatomy. — There are two varieties of cerebral hemorrhages: one consisting of minute blood-extravasations, or points ; the other of clots of varying size. Preceding either form, the vessel ruptured is the seat of miliary aneu- rism ; these aneurismal dilatations upon the arteries are caused by a peri- arteritis, commencing in the lymph-sheaths of the vessels and advancing to the tunica adventitia and the muscular coat. Minute blood-extravasations play an important part in the development of apoplexy. Little foci sometimes occur within the cortex of the brain as the result of venous thrombi, but these are probably soon absorbed. You may find them accompanying cerebral softening, and also in the neighbor- hood of large apoplectic spots. A congregation of these pin-head extravasa- tions may constitute apoplectic foci. At an autopsy we usually find irregularly spherical clots of blood, varying in size, but usually about three-fourths of an inch in diameter, imbedded in the cerebral substance. In the aged, often a large portion of the brain is occupied by the extravasation. The favorite localities for these hemorrhagic extravasations are the in- traventricular nucleus of the corpus striatum, the extraventricular nucleus, the thalamus opticus, the cerebellum, and the pons. More frequently in the aged than in others will you find the corpus striatum pushed up and surrounded by the extravasation, instead of having an effusion into it ; this is best seen in the ventricles, which may also be the seat of hemorrhage, sometimes so extensive that their septa are torn and blood escapes upon the surface of the brain. In the aged you will quite often notice apoplectic foci between the mem- branes in the subarachnoidean space, or even superficially. The locality of the extravasation is determined by the arterial distribution, as the vessels to those parts already named are the most direct continuation of the carotids. The cerebral convolutions are flattened and the sulci deepened when 232 CLINICAL LECTURES ON the extravasation is extensive ; the dura mater is stretched, and sometimes there is a visible bulging, for, in advanced life, large hemorrhages are rather the rule. The clot, or "focus," is a soft, grunious mass, at whose centre is the opening into the ruptured vessel. Its wall consists of shreddy, cerebral matter, mingled with fibrinous fibrilhe, the result of the hemorrhage. When the apoplectic stroke, as it is called, is not immediately fatal, the clot may undergo three changes : 1st, its fluid may be absorbed ; 2d, it may undergo fatty degeneration and be absorbed ; 3d, it may excite in- flammation in the surrounding brain-substance, and lead to red softening. In all cases the brain-substance in the immediate vicinity of the clot is somewhat cedematous, and slightly yellowed. The secondary changes consist in the transformations of the clot into a cyst, whose contents vary in color from a pale yellow to a dark brown, according to the number of blood-corpuscles that undergo pigment de- generation. The cyst-wall is firm, smooth, connective tissue. A cyst rarely becomes an abscess of the brain in the aged. Cicatricial tissue may forni from the cyst, although it is, at present, a mooted question whether a cyst must necessarily pre-exist in order that such a cicatrix shall form. It takes about two years, in old people, for such a cicatrix to fomi and the cyst to be absorbed. There may be a number of these cysts or cicatrices in the same brain, corresponding to the number of apoplexies. Crnveilhier states that he found fifteen in one brain. They cause " puckering " of the brain-substance. The nerves connected with the parts involved may undergo degenera- tion, and general atrophy of the brain may ensue. Etiology. — Tho most powerful predisposing cause to cerebral hemor- rhage is age. It rarely occurs before forty, the liability to it increasing with advanced years. It is generally stated that the tendency ceases at about seventy; but this is not so, for the comparatively small number of people living over seventy has not entered into the statistical estimate. The causes which predispose to apoplexy are fatty, atheromatous, or fibroid degeneration of the walls of the vessels ; hence, the importance of gout, rheumatism, syphilis, alcoholismus, and chronic Bright's disease as predisposing causes. Cardiac hypertrophy and dilatation predispose to apoplexy ; aortic in- sufficiency and pulmonary emphysema are also important etiological factors. Softening of the brain, which, I think, follows as often as it prei apoplexy, also predisposes to it. Men are far more liable to cerebral hemorrhage than women, on account of their active mode of life and their greater liability to excitement. Apo- plexies also occur much more frequently in cold than in warin weather. The exciting causes may be summed up in the phrase, dm \oodr pressure : although a cerebral hemorrhage may occur without any such in- crease, at least so far as we can discover. Coughing, running, a fall, violent emotion, the venereal act (the latter especially) are frequently exciting causes of apoplexy in the aged. A cold bath, by constringing the cutaneous vessels, may be an exciting oaO£ The so-called "plethoric habit." which causes in some so much anxi has no significance, for the emaciated valetudinarian is just as liable to apoplexy as he of the opposite condition. There is in certain persons an hereditary tendency to arterial degenera- tion which predisposes to cerebral hemorrhage. Symptoms. — There may or may not be prodromata of a cerebral apo- plexy. When the latter are present they may appear either in the form of THE DISEASES OF OLD AGE. 233 vertigo, muscse volitantes, double vision, temporary blindness, tinnitus au- rium, complete deafness, an abnormally keen sense of smell, or a total loss of it. These are, however, unimportant, compared to loss of memory, diffi- culty of speech, lethargy, or stupor, and a feeling of weight, numbness, or formication that very commonly presages a fit of apoplexy, and which should always excite alarm when present during the senile period of life. Bepeated epistaxis is another important prodromal symptom. These premonitory signs may be* absent, and the attack be instan- taneous, the patient suddenly falling into a condition of coma, with loss of sense, sensation, and voluntary motion ; or, the coma comes on gradually, being preceded by pains in the head and a feeling of faintness ; or, finally, aphasia and hemiplegia are the first and the only symptoms. The attack may be so light as to seem nothing more than a momentary state of insensibility ; and the patient is thought to have had " a fainting- spell " or " a fit of indigestion," since it frequently comes on after an aged person has been over-indulgent at table. Usually, however, the individual is struck down suddenly, and there is complete loss of consciousness for a period varying in length from a few minutes to two or three days. During the state of coma the respirations are deep, slow, and often ster- torous ; the face is either pale, or red and turgid ; the veins are engorged, and as the coma deepens the face assumes a dark, livid hue. A marked pallor may sometimes continue through the whole attack. If the coma last three days, the temperature on the second day is lowered (96° F.) frequently to rise the next day to 107° F. The pulse in old people at the onset of the "fit " is commonly rapid, feeble and intermittent ; later it be- comes slow, full, and regular. As a rule, the pupils are dilated, though at times, while one is of normal size, the other is dilated or contracted. In its worst ioYm—" apoplexie foudroyante" — the breathing is exceed- ingly slow, stertorous, often superficial, interrupted, and irregular. Each expiration is accompanied by a loud " puffing " noise from the lips, and the ejection of a frothy mucus which accumulates about the mouth. Degluti- tion is impossible ; the features are distorted, the pupils contracted, the skin is cold and clammy, and the fseces and urine are passed involuntarily. Death usually occurs, in such cases, in two or three hours. Keflex move- ments may be excited, except in very rare instances. The paralyzed side is usually convulsed from the beginning, and tetanic spasm of a muscle, or set of muscles, occasionally occurs. There is a form of apoplexy which is sometimes observed in the aged, seemingly associated with ventricular effusion— -a general convulsive attack, epileptic in character, where the tongue is often bitten and frothing at the mouth occurs, lasting from fifteen to thirty minutes, which is followed ap- parently by no bad results other than the gradual supervention of extreme debility. But death almost always ensues after a longer or shorter period varying with the age and constitution of the patient. Apoplexy in the aged, is synonymous with hemiplegia, and its evidences are too well-marked to need any lengthy description. The " conjugate de- viation" of the eyes, the protrusion of the tongue toward the paralyzed side, the drawn mouth, etc., these are the common symptoms. Anaesthesia on the paralyzed side commonly occurs, but passes off gradually in most cases. The hemiplegia itself is permanent or temporary, depending on com- plete destruction or only partial implication of the corpus striatum or thalamus opticus. 234 CLINICAL LECTURES ON I shall not attempt to name all the variations due to hemorrhages into the pons, cerebellum, etc. Differential diagnosis. — Cerebral hemorrhage in the aged may be mis- taken for cerebral congestion, uraemia, alcoholic intoxication, and embolism. In congestion there is absence of stertorous breathing, which is always present in apoplexy. The pupils are contracted in congestion, and dilated in apoplexy. The coma is of very short duration in congestion, whereas it persists for some time in apoplexy. Congestion has a long prodromal period ; while it is short, and often absent, in cases of apoplexy. In congestion the paralysis is usually bilateral, while ' in apoplexy it is unilateral. Hemiplegia is rarely present in uraemia, while it is rarely absent in apoplexy. Uraemia comes on gradually, and is usually preceded by convulsions ; while the coma of apoplexy is sudden in its advent, and convulsions never precede it The presence of casts and albumen in the urine establishes the diagnosis between uraemia and apoplexy. Alcoholic intoxication is often mistaken for apoplexy. The patient can easily be roused from alcoholic coma, while this is not the case with cerebral hemorrhage. There is no stertor in alcoholic coma, whereas it is usually present in uraemia. The pulse is feeble and frequent in alcoholic coma, while it is full, strong, and slow in apoplexy. There is no hemiplegia in alcoholic coma, while it is an exceedingly common condition in apoplexy. Lastly, the urine may be tested for alcohol as follows : to fifteen min- ims of a solution consisting of three hundred parts of strong sulphuric acid, and one of bichromate of potassa, add a few drops of the suspected urine ; in case of alcoholism, the mixture tarns an emerald green. Cerebral embolism rarely occurs in the aged, and is accompanied by tory of rheumatism or rheumatic endocarditis and valvular disease of the heart. In embolism, the patient does not lose consciousness ; in apoplexy there is loss of consciousness. The pulse is rapid and feeble in embolism, and the face is pallid ; in apoplexy the pulse is slow and full, the face is red and turgid. Aphasia is rare in apoplexy, while almost pathognomonic of embolism. The pupils are unaltered in embohsm, while in apoplexy they are usually deviated from the normal. There is stertor in apoplexy, whereas in embolism the breathr. normal. Paralysis is usually on the right side in embolism, while it is on either side in cerebral hemorrhage. Evidence of arterial atheroma is usually present in apoplexy, it may be absent in cases of embolism. The paralysis improves in forty-eight hours, in embolism, while in apopk is of much longer duration, and is rarely entirely recovered from. Prognosis. — The prognosis in the apoplexy of old age is always grave. If the first attack is recovered from, it is almost always followed I g within a year ; a third attack is almost always fatal. The greater the age, the greater the danger. Persistent coma, loss of control over the sphiucters. dysphagia, " pin- head "pupils, a temperature over 100° Fahr., and a "puffy " expiration, are THE DISEASES OF OLD AGE. 235 all unfavorable symptoms ; and convulsions, indicating that the hemorrhage has involved the meninges, are generally soon followed by death. The general condition of the patient, and his freedom from disease, will likewise influence the prognosis. Never give a positive prognosis until at least two weeks have elapsed after the attack. Even after so-called recovery has taken place in the aged, there is more or less loss of mental power, so that the patient is incapable of transacting business accurately, and even the power of reading, or the memory of cer- tain words, is wholly lost. The more complete the paralysis, the less the chance of recovery. Treatment. — The prophylactic treatment resolves itself into avoidance of sudden violent physical exertion, or of strong emotion. The diet should be simple and non-stimulating. The clothing should be worn loosely, and there should be free ventilation in the living and sleeping apartments. Sudden extremes of temperature should be avoided ; hence, hot and cold baths are contraindicated. Attention must be paid to the bowels, and, in the advent of premonitory symptoms, active purgation and blisters to the neck will be found of service. Alcoholic beverages in excess are most harmful, but light wines, in moderation, do no injury. The bromides of lithium and zinc oxide are often administered with advantage when cerebral hemorrhage threatens. Finally, remember that you are dealing with old age, and that the patient must not be debilitated. When an attack or " stroke " has occurred, the first things to be done are to elevate the patient's head, loosen the clothing about the neck, and have the apartment kept dark and absolutely quiet. The air about the head may be kept cool by ice-bags, and the feet are to be placed in a hot mustard-bath. Under no circumstances should bloodletting be practised in the treat- ment of apoplexy of old age. The bowels should be moved by drastic cathartics, sufficiently to induce the so-called "revulsive" effects. Much of the venous turgescence of countenance may be due to stertor from falling back of the tongue ; hence, place the patient on his side, and it will frequently disappear. Emetics are never to be administered. Sina- pisms may be applied to the nape of the neck, calves of the legs, and over the stomach, their size and number being determined by the condition and age of the patient. When the vital powers are greatly depressed, when there is extreme feebleness and pallor, internal and external stimulation must be resorted to ; milk, beef-tea, and brandy are to be given freely. Iron can be ad- ministered to the aged in nearly all cases of cerebral hemorrhage^ The "hydropathic" treatment is now seldom resorted to for the hemiplegia which follows apoplexy in the aged. Mild narcotics are to be given in case there is much sleeplessness and irritability, but only after a lapse of two or three weeks. W T hen all symptoms of cerebral irritation have passed, faradization may be employed ; and phosphorus and strychnia (the latter hypodermically) may be given with advantage. I now invite your attention to the study of senile softening of the brain. 236 CLINICAL LECTUEES ON Cekebral Softening. Cerebral ramollissement, or encephalomalachia, is a disease peculiar to old age. It is one of the most frequent cerebral diseases of advanced life. Morbid anatomy. — This condition has, in reality, been studied only with- in the present century ; and many theories have been advanced as to its nature and pathogenesis. Some claim that it is always the result of inflam- mation ; others say it is a variety of gangrene ; arid still others, that it is the result of a chemico-pathological process. Three forms are discoverable at the autopsy : the red, the yellow, and the white softening. The red has been called acute or inflammatory ; and the white, chronic or non-inflammatory softening, though this distinction cannot always be demonstrated. I. — Red softening is first marked by stasis, rapidly followed by fatty de- generation of the cells and nerve-fibres. The pultaceous tissue is of a deep red color, or the discoloration may occur in sj)ots as numerous foci in dif- ferent stages of softening, the processes in either case being best marked at the centre of the softened mass or masses. The vessels are filled with coagulated blood, their contents undergoiug a retrograde nietainorphosis, and the fibrin becoming granular, the infarction becomes dry and shrunken, cicatrization may occur, or there maybe liquefaction of the content- the formation of cysts. Increase in specific gravity in red softening occurs in a few instances, although decrease is the rule. The microscope reveals the presence of fat-granules, altered blood-cor- puscles, and large granular corpuscles ( Oluge't corpuscles) from the cells of the neuroglia. The capillaries are dilated and tilled with coagula. and the white substance of the fibres is coagulated or broken up into large masses of myeline. This variety of cerebral softening is properly called : its color is due to its sudden occurrence, the subsequent pathological change! being common to all {Jure form*. II. — The softening from anamiia, i.e., from obstruction in the vesst called yellow softening. It may occur at any point in the brain, but its most frequent seat is in the middle or posterior lobes, and in the convolu- tions or corpus striatum. It is often the color of sulphur, varying in size from that of a hazel-nut to that of the fist ; it may involve a whole hemi- sphere. Its consistence varies, but in typical cases it is a gelatinous, moist, and tremulous pulp. Later on the so-called "cellular infiltration " of the French writers occurs : the implicated spot is metamorphosed into a mass of reticulated fibres, in whose meshes is a milky, chalky fluid. This is a sort of reparative process, having its analogue on the surface of the brain in the yellow plaques made up of tough, pliable, ochre-colored con- nective tissue containing nuclei, crystals of haematm and hirmatoidin, and a few fat-corpuscles. When cut across, one of these spots rises above the level of the section ; a gentle stream of water will wash away the softened tissue from the surrounding cerebral substance. In all varieties of soften- ing there is usually no well-marked line of demarcation : the healthy and diseased parts insensibly run into each other. In the yellow variety we can occasionally find traces of demarcation. The color of yellow softening depends on a closer congregation and ■ finer subdivision of the fat-globules than occurs in white softening, though changed blood-pigment sometimes gives it its yellow color. THE DISEASES OF OLD AGE. 237 HI.— White, atrophic, or chronic softening is the variety most frequently met with in the aged. It is white, or resembles healthy brain-tissue, for the reason that the process takes place slowly, and hence hyperemia or hemorrhage is very slight or wholly absent ; often the implicated spot is as difnuentas cream. The other pathological appearances are the same as in yellow softening, with which it is identical, except in color. There is a decrease in the specific gravity of brain-tissue that has un- dergone white ramollissement. Etiology. — I have said that the difference between red and white or yellow softening, as marked by the terms acute and chronic inflammatory and non-inflammatory, is not exact. Its etiology will explain this. Encephalomalachia is frequently the result of embolism, thrombosis, or hemorrhage. And since almost all the predisposing causes of thrombosis are met with in advanced life, thrombosis is by far the most frequent cause. It sometimes results from syphilitic disease of the arteries. It is quite well established that in advanced life severe and prolonged intellectual efforts or exercise of the emotions will cause cerebral softening ; blows, or the action of intense cold on the head, and alcoholismus act also as causes. Atheroma in predisposing to thrombosis is a powerful factor, and the pressure of intracranial tumors has been known to produce ramollissement. •Cardiac valvular diseases exert a most powerful influence in the develop- ment of cerebral softening. The liability to cerebral softening steadily increases with advancing age. Bed softening may be caused by embolism or thrombosis, and is then sudden ; or the vessels in chronic white softening may rupture, and the blood extravasated give a red color to the softened mass. Yellow softening may be, and commonly is, as I have said, a variety of white ; in some instances it primarily results from embolism or thrombosis ; a gelatinous oedema about cerebral neoplasia has been denominated a yel- low softening. White softening may in rare instances be acute, from a sudden obstruc- tion by an embolus in one of the larger arteries ; it may be due to the senile change in the vessels, and it may result from feeble heart-power. In some instances there is no discoverable cause. At my next lecture I shall speak of the symptoms and diagnosis of cere- bral softening. 238 CLINICAL LECTURES ON LECTURE XXVIII. CEREBRAL SOFTENING. Summary. — Symptoms — Differential Diagnosis — Prognosis — Treatment — Senile Cere- bral Atrophy — Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treatment. Anatomicnl and Physiological Changes in the Alimentary Canal in Old Age. Chronic Senile Gastric Catarrh ,,Dyspepsiaj — Morbid Anatomy — Etiology — Symptoms — Differential Diagnosis. Gentlemen : — In acute cerebral softening prodromal symptoms frequently exist. These premonitory si, similar to those of apoplexy ; although formication, aching, and cramps of the limbs, and anomalies in the sense of touch, are much more prominent in commencing ramollissernent. Local inequalities of temperature are occasionally among the prodromata. There* is also a diminution in the motor power ; when thw in im- portant sign. "When prodromata occur, the symptoms either gradually in- crease, or else advance by sudden exacerbations with intervals of apparent improvement — the affected side grows weaker and weaker, the lingers, hands, and feet are managed clumsily, the leg trembles under the body, there is a tottering gait, and, finally, decided para 1 ,; It now either assumes the " chronic '* form, or typhoid svmptoms come on, and death speedily occurs, often from complications in the n organs ; the older the patient, the less likely are we to have premonitory signs. Often the attack simulates cerebral hemorrhage so closely that a dif- ferential diagnosis is impossible. In acute cases, withoui prodromata, the patient becomes suddenly para- lyzed without loss of consciousness, or is paralyzed and comatose ; but he soon comes out of the coma with impaired or l<>*t speech. Y very constant symptom, and when headache is present on the side opposite the paralyzed one, it is almost diagnostic. In some cases a mild delirium, a "wandering" as it is called, of - duration may mark the onset ; this occurs most frequently in very old per- sons. The eyeballs are directed to one side, although the featun metrical until active movements are made. Muscular rigidity, spasmodic twitching, difficult deglutition, suffusion of the eye, are usually present ; the urine and faces are passed involuntarily, bedsores form, the pulse grows more rapid and feeble, and the patient finally dies from exhaustion. Chronic softening is for weeks or months preceded by gradually increas- ing feebleness, loss of memory, fretfulness, and tits of uncontrollable weeping — rarely laughing. There are dull pains, or M a sense of confoe in the head : there is general loss of muscular power, with difficult "thickness" of speech. The patient becomes perfectly listless and tl. a marked change in disposition. Then comes partial paralysis of one side, and finally the patient becomes perfectly helpless and childish, and THE DISEASES OF OLD AGE. 239 lie is incapable of retaining the contents of his bladder and rectum. Aphasia, from plugging of the left middle cerebral artery, is a symptom which frequently accompanies chronic softening. When paralysis begins at the distal end of a limb and approaches by degrees the trunk, it is called " creeping palsy." The intellect is much oftener affected in chronic than in acute ramollis- sement, and febrile symptoms are exceptional occurrences. The bowels are commonly constipated, the appetite and the body weight usually remain at the normal standard, and the patient is disposed to sleep the greater part of his time. In some cases there are no symptoms to mark its presence. Differential diagnosis. — The differential diagnosis between cerebral soft- ening, apoplexy and embolism we have already considered. In some instances the symptoms which attend the development of tumors of the brain may be mistaken for those of cerebral softening. The history, in cerebral softening, usually elicits cardiac disease or atheromatous arteries ; while carcinoma and gummata, the most frequent senile cerebral neoplasia, will probably have a history of syphilis or cancer. Localized pain in the head is a prominent and almost constant symp- tom in cerebral tumor, while the headache is dull and diffused, often absent, in softening — pain is not a necessary symptom of softening ; this is one of the chief points of its diagnosis. The speech and intellect are unaffected in tumors ; whereas both are early implicated in cases of softening. Symptoms referable to some special cranial nerve or set of nerves are present in cases of cerebral tumors, and absent, as a rule when softening exists. The face is prominently implicated in the paralysis from tumors, while hemiplegia is the rule with softening. Epileptic convulsions, independent of paralysis, occur frequently with tumors, but they do not exist in cases of cerebral softening. If tumors are syphilitic, the symptoms which they give rise to improve under large doses of iodide of potassium, while this drug has no effect in cerebral softening. Prognosis. — Senile cerebral softening is regarded as inevitably fatal. In acute softening death has often occurred on the first day, and life is not prolonged over ten days. Chronic cerebral softening is very varying in its duration ; cases have been reported where the symptoms were well marked and extended over a period of four years. Death may directly occur , from the softening, either from interference with respiratory apparatus, or from the complications, such as bronchitis, pneumonia, meningitis, hypostatic congestion of the lungs, diarrhoea, ex- tensive sloughs on the sacrum and hips, hemorrhage into the softened mass, or from exhaustion. Treatment.— When the premonitory symptoms of cerebral softening oc- cur the strictest attention must be paid to the diet, which must be simple, nutritious, and easy of digestion. The surroundings of the patient should also be regarded, and no excitement or over-exercise allowed. These patients should never be allowed to become constipated. Milk is the best article of diet in these cases. When there is excitement followed by sleeplessness or headache, the bromides may be administered ; and Indian hemp is regarded by some as a most useful drug in this condition. When softening is established, benefit is often obtained from zinc, phos- 240 CLINICAL LECTURES ON phorus and strychnia, and the tonics iron and quinine are beneficial in nearly every case. The constant current, alternating with faradization, is to be given with great care. When cerebral softening simulates apoplectic seizures, the same recum- bent posture, cool surroundings, quiet, etc., must be preserved as were advised in cerebral hemorrhage, and the bowels must never be allowed to become constipated, you will find this to be the tendency in the vast majority of cases. When bedsores and sloughing threaten, they must be promptly combated, for the strength of the patient is greatly diminished by them, and in the aged they are very obstinate and often cause death. Blistering, counter-irritation and bloodletting are contraindicated in all cases. The last senile cerebral disease which I shall consider is Senile Cerebral Atrophy. Morbid anatomy. — In senile atrophy there is actual diminution in the cellular elements of the brain, and a loss in its interstitial connective tissue. The cells of the cortex are swollen and pigmented, and pigmenta- tion also occurs in the walls of the vessels which are commonly the seat of fatt} r degeneration. Corpora amylacea are present in the vast majority of cases, especially in the thinned cortex. In general it may be said there is decrease in the fat, and increase in the water of the brain-substance. Senile atrophy is usually complete ; when partial it affects the left hemisphere. There is unequal thinning of the convolutions, and the sulci are larger and deeper. There is increased consistence, often long! of the brain, the meninges are clouded, and the ventricles are dilated with fluid, varying in amount from two to twelve drachms ; this must 1 garded as a purely conservative process. Serum likewise fills the subaraeh- noidean space. An attempt to cut the brain shows it to have a leathers- tough and the section is frequently corrugated : the medullary portion will have a dull white or drab color, and the cortical substance will be darker than normal. Cases occasionally are found where the arachnoid covering the hemi- spheres is in juxtaposition with that of the ventricles, there I substance between : again, only a thin layer of areolar tissue may intervene between these two membranes. Etiology. — Atrophy may follow a hemorrhage or softening, and is occa- sionally caused by tumors and inflammation of the coverings of the brain. Injury or destruction of the peripheral nerves may induce secondary bral atrophy. But the great cause is senile marasmus. Symptoms. — The mental faculties in senile cerebral atrophy gradually become weaker and weaker ; there are loss of memory and blunting of the special senses ; and the movements, from being unsteady, are soon accom- panied by tremor. The patient becomes childish, apathetic, and is constantly sleepy or asleep, and nearly all control over the sphincters is lost. The disease finally ends in invasion of the medulla, implication of the centres situate therein, and deglutition or respiration, or both, ai much interferred with, if not annulled, as to cause death. It may be that general paralysis of both sides of the body occurs, and then complete imbecility usually supervenes. THE DISEASES OF OLD AGE. 241 Differential diagnosis. — This is made from softening and hemorrhage only, by exclusion and a careful consideration of the history. Prognosis.— -This is always unfavorable ; no estimate can be made as to the length of life, and the intellect and forces cannot be rallied by any known means. Its duration is uncertain. Treatment. — Treatment is out of the question ; we can only build up the patient by means of a good diet and tonics. I shall now pass to the consideration of senile diseases of the digestive apparatus. The most common and important of this class is Chronic Senile Gastric Catarrh. The digestive apparatus participates in the general atrophy which occurs in all the tissues in old age. The stomach and intestines lose bulk, and their mucous membrane is markedly thinned. The glandular system is more or less atrophied, and many of the glands seem to have entirely disappeared. Not only is the gastric mucous mem- brane thinned, but it is also paler than in adult life, usually acquiring an ashy gray color, which is more pronounced the older the individual. The vessels of the mucous membrane, the veins especially, are dilated and varicose. The glands in the stomach are occasionally so impregnated with melanin that they have a punctated look, resembling the cutaneous surface when filled with specks of gunpowder. Numerous small yellow spots (groups of glands filled with fatty matter), occur in the gastric mu- cous membrane in that condition known as senile marasmus. The duo- denum, jejunum and ilium undergo more extensive wasting of their coats than occurs in the stomach ; indeed, these structures are sometimes so attenuated that at the autopsy their contents are distinctly visible through their walls. It may be mentioned that the large intestine does not exhibit so much wasting, since there is more or less compensatory hypertrophy of its mus- cular coat. Atrophy of the jaws, the lower especially, results from loss of the teeth, a common condition in old age ; and even on the surface of the tongue we find that thinning of the digestive mucous membrane already referred to. The physiological results of these conditions are a blunting of the sense of taste, more or less dysphagia, and difficult mastication ; a slow and im- perfect stomach and intestinal digestion. As old people lose their teeth and their power of mastication, they con- sume less bread and meat, as well as other solid food ; hence, chronic anaemia becomes a physiological condition in many old people. The re- sult of all these changes is a diminution in the absorption of nutritious elements. In this connection, it may be stated that in old age the bile is much richer in cholesterin than in adult life. The salivary glands, the pancreas, and the mesenteric glands share in the general glandular atrophy. Senile gastric catarrh, known also as chronic gastric catarrh of the stom- ach, catarrhal gastritis, and follicular dyspepsia, is very frequently met with in advanced life. Morbid anatomy.— You find, on examination of a stomach which is the seat of these changes, no such thick layer of mucus as is present in the gas- tric catarrh of adult life ; it must be remembered that the secretion of mucus is very much diminished in old age, both as a result of the senile 16 242 CLINICAL LECTURES ON state, and also as a result of diseased process. Some mucus, however, is found in every case. There are sometimes ecchymotic spots on the mem- brane, the result of hemorrhages from the varicose vessels. The color of the mucous membrane varies ; sometimes it retains its natural color, but oftener it assumes a reddish brown, slaty gray, or dirty blue appearance. The membrane is unevenly thickened, tougher than normal, and is very loosely connected with the cellular tissue beneath. In old age it is often corrugated, or thrown into furrows ; and villous projections one-fiftieth of an inch in height, filled with granular corpuscles, are found near the pylorus. Mucous polypi are almost exclusively limited to the stomachs of old people with chronic gastritis ; they are either sessile or pedunculated, and their nature and consistence vary according as they are composed of fibrous- tissue, papilke cysts of the obstructed glands, or of all these united. "Ulceration, thickening, and induration of the diseased membrane is of frequent occurrence, the ulcers being superficial, limited to the mucous coat, and, by their aggregation, a large extent of the membrane may suffer abrasion. "When the disease has existed for a long time, the mucous membrane has a granular or mammillary appearance which results either from obstruc- tion to the exit of the secretion from the tubules (thus causing tbem to stand out on an atrophied tissue), or mammillation may result from actual hypertrophy of the glandular layer. The microscope may show the tubules to be completely filled with fat-globules, or the epithelium to have under- gone fatty degeneration. In other cases the tubules will be found filled witli a granular detritus, and their epithelium will have undergone granular degeneration, which at the base is sometimes darkened by blood-stains. In whatever condition their contents may be, the mMOOUM foU vile chronic catarrh arc always enlarged, sometimes visibly so. By many these are regarded as the est 4 of the dtMHA In long-continued gastritis the submucous coat becomes involved, and more or less thickening and congestion occur in it. If there is an infiltration into this layer, its organization and subsequent contraction may hinder still more the peri- staltic motion already impeded to a greater or lesser extent by the senile intestinal changes already referred to. In many old people who have for years suffered from this disease, you may even find the muscular coat involved in the process of thickening, and this additional pathological lesion will reduce peristalsis to a minimum. Etiology. — Undoubted examples of primary acute or subacute gastritis are seen in old age. These are very rare, however, at this period of life, and may be thrown out as etiological factors, senile gastric catarrh being chronic from its commencement. Catarrhal dyspepsia is in old age very frequently associated with, and appears to be secondary to chronic bronchitis, bronehorrha-a, and chronic disease of the heart. One very important cause is ana?mia ; the senile anreniic condition which I have already referred to. Long-continued, passive hyperemia, the result of obstruction to the portal circulation and pressure froin tumors, acts as a producing c though not as frequently as chronic bronchitis and organic t the heart. Many old people will give such a clear history of ancestral dys- pepsias that there is no doubt but that the disease is sometimes hereditary. Old people who habitually eat too rapidly or too much, or wb< large quantities of food which in youth their stomach could manage, but THE DISEASES OF OLD AGE. 243 ■which, at this period of life, is utterly indigestible, always have embarrassed digestion, or, as they prefer to call it "a morbidly sensitive stomach." Again, unless the greatest care be taken, even slow and moderate eaters will, when their teeth drop out or decay, suffer from this painful condition on account of insufficient mastication. Immoderate smoking or snuff-taking may, in advanced life, induce catarrhal dyspepsia. Finally, alcoholic beverages, too little exercise, mental strain or physi- cal labor immediately after taking food, and irregularity in the time of eating, are very often followed by " dyspeptic " symptoms in the senile period of life. Scrofula, syphilis, and gout, undoubtedly predispose to, and the latter actually excites senile chronic gastritis. Symptoms. — In old age, you will find that chronic catarrh, or, as it is usually called, " dyspepsia," appears in a variety of ways. Some old people say their stomach was always weak, or that certain articles, mentioning those which they eat most of, always disagreed with them. Others, again, are truly great sufferers, and in them the condition amounts to more than an infirmity of advanced life. There is generally a sense of weight and fulness in the region of the stomach, either constant, or coming on in from one-half to an hour after the ingestion of food. Anorexia is present in nearly all cases of well-developed senile gastric catarrh, and the only food that is relished is that of a piquant and highly seasoned kind ; they cannot bear oily food. This anorexia soon leads to a well-marked anaemic condition, and to an exhaustion which is far more dangerous than the emaciation accompanying it ; thus, anorexia must be looked upon as a serious symptom, and one to be promptly combated. Accompanying the anorexia there is commonly great thirst, especially for acid drinks. Old people with catarrhal dyspepsia vomit, or rather regurgitate, every morning, or at some other period of the day, more or less glairy mucus, just as bronchitic individuals "raise" phlegm of a morning on rising. These old people can, or do, regurgitate this mucus, and yet retain the contents of the stomach perfectly well. Nausea is far from infrequent in these cases, but very rarely is accompanied by vomiting. Flatulence and heartburn are so common in many old people as to be regarded as the natural attendants of old age. Heartburn or cardialgia arises from the acid mucus which is belched up into the oesophagus. Flatulence is sometimes the chief sign of this condition and is always very distressing ; it is most annoying during or a little after the period of digestion, though you wall find some old people complaining of it when the stomach is empty. Old gourmands form the greater part of the former, and chronic tipplers of the latter class, for self-evident reasons. Flatulence is sometimes so great that the distended stomach and intestines feel " sore," and are painful to the touch. Pyrosis, "water-brash," or black water, as it is variously styled, is often present in old people, in women especially, as a chronic and obstinate ac- companiment of catarrhal dyspepsia. The fluid is thin, watery, colorless, and either insipid to the taste or so acrid and sour that it sets the teeth on edge. More or less pain precedes the gush of liquid into the mouth, which is followed by almost immediate relief. You will find pyrosis com- monest in old people who are ill-fed, poorly clothed, and who live princi- pally upon vegetable food, or are habitual spirit-drinkers. _ Pyrosis may occasionally be° so great as to amount to gastrorrhoea, a condition analogous to the blennorrhoea of other parts. Gastrodynia, more or less severe pain in the stomach, is by no means an 244 CLINICAL LECTURES ON infrequent symptom of senile gastric catarrh, and it is met with as well when the stomach is empty as during the various periods of digestion. Sometimes the pain is diffused, and again it is confined to a spot no larger than a silver dollar ; it is relieved by pressure. ' The tongue is usually pale and flabby in old subjects who have long suffered with gastric catarrh ; often it is indented with the marks of the teeth. It may be studded with minute aphthous ulcers. The tongue in other cases has a peculiar " sodden" look, or may be perfectly normal even in very obstinate and prolonged cases. The breath is always offen- sive in these old patients. The texture and color of the skin, hair and nails are altered from the normal, and present a shrivelled appearance. Old people who have long suffered from catarrhal dyspepsia are rarely free from hemorrhoids ; they are also habitually constipated, intercurrent attacks of diarrhoea being, however, far from infrequent, and you may find large quantities of mucus mixed with scanty alvine dejections. The urine is scanty, dark-colored, sometimes depositing urates, phos- phates and oxalates, although it is far from ben, limentary as in adult life. It is often clouded, even at the time of emission. The specific gravity varies with the diet and the time when voided, as for instance, whether morning or evening. Finally there is a train of symptoms called u sympathetic." which occur late in the disease, and undoubtedly arise from the gastric disturbance. Hypochondriasis, despondency, mist rust of old friends, and irritability of temper are common in these cases ; there is either sleeplessness, or tho sleep is disturbed. Dyspnoea, sighing, chilly sensations about the ex:, ties, slight febrile reactions, preceded by rigors, slight night-sweats and an icteroid hue of the conjunctiva?, these are rarely absent in cases of senile gastric catarrh. Differential diagnosis. — Chronic catarrh of the stomach, or catarrhal dyspepsia, may be mistaken for ami I The points in the differential diagnosis between senile gastric catarrh and ammonaania will be considered under the heed 1 t Ammonamia. Atonic dyspepsia occurs in those whose pursuit or mental condition is accompanied by great depression, wh arrhaldyt iated with chronic cardiac, pulmonary or hepatic disease, or is induced by "tippling." There is no pain or tenderness over the epigastric region in atonic dyspepsia, while these are never absent in senile chronic gastritis. The tongue is pale, broad, and flabby in atonic dyspepsia, and often c» with a thick coating in chronic gastric catarrh. Anorexia and thirst are marked symptoms in senile chronic gastritis, while thirst is not a prominent symptom of atonic dyspepsia, and tite is slightly, if at all altered. In atonic dyspepsia there are no constitutional or sympathetic symp- toms, while progressive emaciation, weakness, a jaundiced, sallow, or earthy color to the skin, a well-marked cachectic state, and disordered mental con- dition, are prominent in chronic gastric catarrh. The alterations in the urine of chronic gastritis, which I have just given, are not found in atonic dyspepsia, the secretion being normal. Finally, the bowels are regular in atonic dyfi bile in senile trie catarrh they are constipated, slight attacks of diarrhoea, occurring at varying periods in the course of the disease. I shall continue this subject at my next lecture. 1 The subject of gouty gastritis has been referred to by Professor Charcot in pre- vious pages of this book. THE DISEASES OF OLD AGE. 245 LECTUEE XXIX. CHRONIC GASTRIC CATARRH. Summary. —Prognosis— Treatment. Diarrhoea in Old Age— Etiology— Symptoms— Varieties— Differential Diagnosis — Prognosis — Treatment. Constipation in Old Age — Etiology — Symptoms. Gentlemen :— The prognosis in the catarrhal dyspepsia of old age is always good ; it is rarely a direct cause of death. The prognosis for recovery depends on the age ; when over seventy, if it has existed a considerable time, it is incurable. It also depends on the power or will of the patient to conform to the diet and regimen prescribed, and finally on the causative or complicating diseases. You will, therefore' carefully study the thoracic and hepatic conditions of an old person with chronic gastric catarrh, before giving what should always be a guarded prognosis. Treatment. — All medical treatment is secondary to diet and regimen. Abernethy said that a man could not be induced to attend to his diges- tive organs till death, or the fear of death, stared him in the face. Indeed, in many instances a cure can be brought about by regulation of the diet alone, when there is no organic disease complicating the ca- tarrh. When complications exist, the treatment resolves itself into the re- moval of the cause. This effected, the disease becomes readily amenable to treatment. A diet for an old person with chronic catarrhal dyspepsia — subject of course to such variations as shall be indicated by the patient's idiosyncrasy — is the following : First, it must be remembered that the greatest regularity as to the time of meals must be preserved ; the number of the meals should be four or five, rather than three. Five or six hours must intervene between the times of taking food, to give the stomach its needed repose, and the pop- ular error of thinking that, as age advances, the quantity of food must be increased, should always be avoided, for excess in old age means disease. On rising, the patient should always take a glass of fresh milk, contain- ing either soda- or lime-water ; and when the strength and age do not contraindicate, a " rub-down " with a coarse towel will be found to have a wonderfully refreshing effect, and the relation between a brisk feeling of well-being and the appetite is too well known to need comment. At breakfast the aged patient may have weak tea or milk, fresh eggs lightly cooked, a chop not too well done, stale bread with but little butter. Luncheon may consist of oysters, or, when no meat has been taken at breakfast, of a chop or piece of mutton, a glass of old sherry, with perhaps an egg in it, and yesterday's bread. Or the luncheon may be some fresh broth, a sandwich of grated fowl, a glass of sherry or bitter ale, and bread. 246 CLINICAL LECTURES ON If any fruit is taken, it must be either at breakfast or luncheon. ' Dinner should be made of fresh, light fish, mutton, game, tripe, or underdone beef, floury potatoes, light vegetables, and a glass of sherry or claret ; or, when it is indicated, a little brandy arid soda-water. Before retiring, a dry biscuit with milk and arrow-root, or a little brandy may be taken. All the food is to be thoroughly masticated, and eaten very slowly. A few words as to what must be avoided in the diet of the aged. Too much liquid at meals is injurious ; for it dilutes the gastric juice, impedes digestion, and, if excessive, relaxes the stomach. Tea, coffee, cocoa, and milk may be taken in moderate quantities with benefit, but are least objectionable an hour after meals. Broths containing vegetables are extremely indigestible in the stomachs of the aged, and butter and cheese must be rare articles of diet. Over-done, well-done meat, fresh bread, cabbage, carrots, turnips, veal, lamb, pork, salt meats, pastry and salads, are to be forbidden in the senile period of life. Bemeinber Watson's saying : " Gout in the stomach should be oftener called pork in the stomach." Shell-fish, lobsters and crabs, and salmon, herring, eels, mackerel and other kinds of rich, oily fish, must be avoided, for they often excite attacks of acute dyspepsia, whose gravity is out of all proportion, apparently, to the amount of the article taken. Fermented liquors and oatmeal very frequently occasion flatulence and acidity of the stomach, so their use must be determined by the effects produced in each individual's case. Variety is necessar . but it should never be at the expense of sim- plicity and wholesonieiKss of the food. Next in importance to the diet, in the management of senile gastric catarrh, is the condition of the bowels. The relief experienced after free alvine discharges is often so great, that the aged patient refers most of his troublesome symptoms to the consti- pated state of his bowels. An aloetic pill may be taken regularly at dinner ; and Hunjadi Janos or Friedrichshall are excellent laxative mineral waters. Bhubarb and soda, or rhubarb and strychnia, are also efficient remedies for the chronic constipation attending senile gastric catarrh. The bowels must be kept regular, and hence the patient should go to stool at some stated time each day, whether desire is felt or not. Exercise in the fresh air, cleanliness, early retiring and rising, and warm clothing, cannot be overrated as adjuvants to the treatment of catarrhal dys- pepsia. A dry climate often produces markedly beneficial results. Anorexia in old age is best treated with aromatic bitter infusions : quas- sia, columba, gentian and Peruvian bark, combined with strychnia, quinine and iron ; and in the morbid sensibility of the stomach of old dram-drinkers, opium in small quantities will in many instances relieve the anorexia. For the relief of the flatulence, the diet should be essentially dry. Vegetables should form but a very slight part of the food taken. Fari- naceous food, potatoes especially, seems to disagree with this class of patients, while spices and the alkalies are often partaken of with bene- fit. Cajeput oil, creosote, sulphite of soda, charcoal, and a combination of ammonia and the compound tincture of sulphuric ether, rarely fail to give at least temporary relief. Cardialgiaj or heartburn from acidity, is to be combated by the ad- THE DISEASES OF OLD AGE. 247 ministration of alkalies. Magnesia, potash and soda are much used, but lime-water in milk acts best, and gives more permanent relief. Minute doses of morphine can be given when hyperacidity causes ex- treme irritation of the stomach ; and bismuth with the bitter infusions also acts beneficially in allaying gastric irritability. In pyrosis much benefit is often obtained by a change in the diet. Minute doses of morphia, with bismuth and bicarbonate of soda, in com- bination, may be given in extreme cases. I have used kino, conium and belladonna with marked benefit in some cases. For the relief of gastrodynia, nitrate or oxide of silver, with iron and rhubarb, has been highly recommended ; but by far the most efficacious drug for its relief is the subnitrate of bismuth, which may be given in doses varying from five to twenty grains, three times a day, for an indefi- nite period. Hydrocyanic acid is a remedy that sometimes acts when all others fail, but it must be used with great care. When an attack of acute gastrodynia plainly arises from an overloaded stomach, an emetic of warm water may be given. Hepatic, cardiac and pulmonary causes are to be treated according to the rules elsewhere given for their management ; anaemia is to be com- bated with iron in the form of chalybeate waters. If the gastric juice appears to be deficient in amount, pepsin and hydro- chloric acid are to be given with the two principal meals of the day. When, in old age, the dyspepsia is of nervous orgin, preparations of zinc, arsenic and phosphorus are useful ; and a " little wine for the stomach's sake " often enables that organ to act more efficiently. DlARRHCEA IN OLD Age. I shall briefly, in this connection, call your attention to a very frequent condition in advanced life. viz. : diarrhoea. Just here it may be said that, when the trouble is of catarrhal origin, the pathological changes and morbid appearances differ in nowise from those of adult life ; but a much milder and less extensive catarrh will induce serious symptoms than in middle life or childhood. Etiology. — This condition is more frequent in those who grow old rapidly, and in many cases seems to arise from a state of the intestinal tract that is part of the senile marasmus ; indeed, the name " senile lientery " has been given to one variety, so common is it at this period of life. Epidemics of diarrhoea are not infrequently met with when large num- bers of old people are crowded together in asylums and hospitals. Errors in diet are prominent causes of senile diarrhoea. Exposure to cold, sudden chilling of the body, and abruptly checking the perspiration are common causes of diarrhoea in the aged. Aged gouty subjects have frequently a peculiar form of diarrhoea, which is intermittent and seems to be a sort of safety-valve, as great relief often follows slight attacks. Diarrhoea is more prevalent in the winter than in the summer months. I do not speak of the diarrhoea which, in the senile period of life, so frequently accompanies hepatic, renal, thoracic and various other chronic affections, and to which the name of symptomatic diarrhoea has not im- properly been given. Symptoms.— 11 Senile lientery " is the commonest form of diarrhoea m the 248 CLINICAL LECTUEES ON aged, and its most usual cause is over-feeding. You will very often find that many perfectly healthy old people have from four to six movements of the bowels each day, and that this condition has not only persisted for a long time, but it is also unaccompanied by any unpleasant symptom ; indeed, some continue to grow stouter while the diarrhoea continues. In this habitually relaxed state of the bowels, the stools are always pul- taceous. This feculent diarrhoea is most marked in those corpulent and sedentary old people whose appetite is undiminished with age, while their stomach and intestines are incapable of their former vigorous action. When a diarrhoea coming on in old age is marked by limpid or brown- ish liquid discharges, it is called 9STOU8 ; it may be serous diarrhoea from the very onset, or it may be the result of neglect or improperly treated senile lientery. In serous diarrhoea the normal faeces are first swept out by the early dis- charges, after which the motions consist of thin, ochry fluid, always offensive, and often frothy. You will find that this form of diarrhoea almost always is the result of exposure to cold and wet ; and at the commencement there may be some slight febrile movement, attended with rigors. When partial or complete retention of the contents of the lower bowel accompanies a serous flux, the motions are scybalous, and the efforts to expel these hardened masses are constant and painful Catarrhal diarrhoea, or the mucous flux, differ in no way from the intestinal catarrh I have elsewhere spoken of, and is quite rare in old age. Bilious dejections are usually attended with considerable exhaustion in old age. The tongue becomes furred, the complexion sallow ; there is head- ache, and there may be a feeling of weight and uneasiness in the right hypochondrium. When they continue even for a short time, the face becomes drawn and haggard, the eyes seem sunken, the pulse is weak and compressible ; the temperature falls sometimes below the normal standard, and the patient dies in a short time from exhaustion. It is to be borne in mind that, in advanced life, an acute diarrhoea may steadily persist while the patient utters no complaint, shows no signs of distress, and still the disease may be rapidly tending to a fatal issue. Griping and tenesmus are symptoms which are much oftener absent than present in senile diarrhoea. Differential diagnosis. — This condition is not likely to be confounded with any other ; but a diarrhoea may turn you away from a dangerous causative state, such as cancerous disease of the rectum or fecal accumula- tions in the rectum and colon. A digital examination of the rectum will generally determine at once the latter condition. Prognosis. — Diarrhoea is never without danger in old age. The outlook- is worse the longer it continues, the more obstinate it is. and the graver its cause, as, for example, it is more serious when associated with cancer or ulceration of the rectum, than when it depends upon simple impaction or an indiscretion in diet. Old age diarrhoea is frequently an attendant of hemorrhoids, and one of its commonest sequelae is constipation. Death is caused by exhaustion. Treatment. — When an old person has been over-indulgent at table, the plainest indication is to rid the intestine of the offensive material, and therefore such a laxative as castor-oil is to be employed. THE DISEASES OF OLD AGE. 249 Saline purgatives should be avoided, for in advanced life great exhaus- tion is frequently the result of a few rapidly induced watery evacuations. Hence it is always advisable to combine rhubarb, or its compound tincture, with the drug we administer ; and if there is flatulence, half a dozen drops of laudanum may be advantageously added. In weak, aged patients, rhu- barb, magnesia, and opium will be found to act remarkably well. When the patient gives a history of a diarrhoea that has continued for some time, so that the bowels may be safely regarded as freely emptied, Dover's powder, combined with some such astringent as krameria or cate- chu, will be found to check it with great promptness. Chalk-mixture, combined with chloric ether and tincture of opium, is also valuable in similar instances. When there is a marked febrile movement, Dover's powder is of the greatest value, and, in cases where prostration is not excessive, it may be combined with mercury and chalk. Wlien the case remains obstinate, and all these remedies have been tried, then you must resort to kino, catechu, logwood, tannic and gallic acids — the vegetable astringents — combined with opium. Finally, the metallic astringents, copper, lead, silver, and iron, may be cautiously employed. When senile diarrhoea is associated with a condition of anaemia, the mistura ferri compositus is of great utility, but, perhaps, the best com- bination under such circumstances is that used in those English hospitals where the inmates are mostly far advanced in life, namely, half a grain of cupric sulphate and a grain of opium twice a day, gradually increasing the dose of the former to three grains. The most rebellious forms succumb to this treatment. When the urgent symptoms have passed, the dilute mineral acids, ni- tric and sulphuric, act beneficially, by first checking fermentative action, and then toning up the relaxed mucous membrane. Suppositories are to be employed when there is much tenesmus, and when either an enema is inadmissible, or it is impossible to administer medicine by the mouth. Should there be any palpable cause which can bo removed, the primary indication is, of course, to remove it. Warmth is very efficacious, and often aids materially in checking a sim- ple flux. An old writer, Wainwright, said : " A woollen shirt mightily con- duces to cure an habitual diarrhoea." Warm flannels should be continu- ally replaced over the abdomen ; and in severe cases recourse may be had to warm poultices or hot fomentations. The food should be of the most non-irritating character ; alimentation must be chiefly amylaceous; and sago, rice, arrow-root, etc., in milk, are best borne. In some cases, wine with this diet seems to aid in checking the diarrhoea ; and if the aged patient have been accustomed to wine for a number of years, it is not advisable to stop its administration. Other stimulants must be avoided, as well as rich and highly seasoned food. It is best that, for a time, all meats should be avoided. It is im- perative that an old person with any form of diarrhoea should have absolute rest in bed, and should avoid any sudden movement or mental excitement. The recumbent posture prevents gravitation, and hence the rapid pas- sage of the fluids over the irritated membrane. A dry, stimulating atmosphere is the best for aged patients who suffer from diarrhoea ; and if the diarrhoea can clearly be ascribed to a malarial cause, large doses of quinine, are indicated. When the principal pathological changes are in the rectum, much benefit 250 CLINICAL LECTURES ON will be derived from starch, enemata combined with opium or biborate of soda ; rest and warmth, a simple diet, and a dry, bracing air will often- times effect what medicine cannot. Hence, hygienic treatment is of the first importance in senile lientery. Next to the diarrhoea of old age comes properly the consideration of constipation. Constipation in Old Age. Habitual constipation is far more frequent in the aged than in adult life. Etiology. — In most instances habitual constipation in the aged arises from loss of power to propel the contents of the intestine onward, and also from a diminution in the sensibility of the lower bowel. It may be caused by diseases of the brain and spinal cord ; senile dementia, atrophy, softening, and hemiplegia are always accompanied by constipation. The abuse of purgatives leads to chronic constipation, and constipation is often one of the results of long-continued senile lientery. The use of opium favors constipation. Collections of impacted fa?ces in the rectum have sometimes been found to surround masses of pills and other sub- stances, such as magnesia, which were given to relieve constipation. Change of diet, scene, or habit, anything interfering with the regular act of defecation, may cause temporary constipation, and this, in ol< is very apt to become habitual. Diminished contractile power of the ab- dominal muscles, the result of excessive development of fat, is a frequent cause of constipation in old age. It ma}' also result from unnatural dryness of the fceces, such, for exam- ple, as occurs in diabetes, where a very large quantity of lluid is carried off by the kidneys. Torpor of the rectum, which may either be primary or follow prolonged inactivity of the upper portions of the large intestine, is a cause peculiar to the constipation of old age ; and it is rare not to find it in feeble, infinn, bed-ridden patients, women especially ; indeed, women suffer much oftener from this condition than men. Constipation occurs more often in the sedentary and sluggish, where the calls of nature are neglected or postponed, in those who allow fecal masses to accumulate in the intestine, and thus diminish its sensi- bility. In such case the constipation may be purely the result of habit, and hence have no other assignable cause. Symptoms. — The aged submit to temporary constipation with indiffer- ence, a blunted sensibility of the intestinal canal favoring this. With the listlessness of advancing years, the dangerous habit of deferring to answer the call of nature leads to habitual constipation. What may be regarded as constipation in one person is regularity in another. Thus, cases are on record where, from boyhood until the seven- tieth year, the bowels did not move more than once a week, and yet the in- dividual enjoyed excellent health. Such individuals do not bear purging, and it is not safe to administer drastic cathartics to them. In those accustomed to take large quantities of opium, the bowels have been known to move only four times in the year. The history of each individual will tell you if the bowels are sluggish, and whether t . to be regarded as one of constipation. When, in an old person with regular habits, two or U a - peas without defecation, there is a sense of local fulness and hi THE DISEASES OF OLD AGE. 251 to piles and flatulence, headache, vertigo, foul breath, anorexia, and well- marked dyspeptic symptoms. The patient is frequently hypochondriacal. If a predisposition to apoplexy exists, obstinate constipation often hastens tha apoplectic stroke. If a condition of constipation persists, vertigo becomes frequent, there are ruuscae volitantes, tinnitus aurium, spasms of dyspnoea, sleeplessness, and occasionally a dull, steady, frontal headache ; the skin becomes parched, shrivelled, and sallow, and is liable to various kinds of eruptions, especially psoriasis, eczema, prurigo, erythema, and erysipelas. Injuries heal very slowly. The tongue is flaccid, and often indented by the teeth. The kid- ney and liver secrete morbid products, or the excrementitious bile being retained in the blood, it is rendered more or less impure. The ilio-hypo- gastric and ilio-inguinal nerves may be pressed on by the distended caecum and adjoining colon, and neuralgic pains in the groin or over the iliac crest may result. Hemorrhoids and flatulence are now marked ; there is more or less un- easiness in the genito-urinary tract because of the pressure from the tumor of indurated faeces, which likewise cause the piles and flatus. The veins of the lower extremity, testicle or ovary, may be pressed upon, and oedema of the feet and varicose veins occur. In prolonged cases the action of the stomach is crippled, and in many cases a cachexia is developed. I shall continue this subject at my next lecture. 252 CLINICAL LECTUIiES ON LECTURE XXX. SENILE CONSTIPATION. Su mmary.— Constipation in Old Age {continued) — Symptoms — Differential Diagnosis — Prognosis — Treatment. Changes in the Bladder and Urine in Old Age — Atony or Paralysis of the Blad- der — Definition — Etiology — Symptoms — Differential Diagnosis — Prognosis — Treat- ment — Chronic Enlargement — Hypertrophy of the Prostate Gland — Morbid An- atomy — Etiology. Gentlemen : — Constipation is felt most from its results. Dilatation and hypertrophy of the intestine are very common conditions in old age. The dilatation begins just above the rectum, extends upward the entire I of the large intestine, the circumference in the latter intestine may m< from nine to twelve inches. Hypertrophy of the intestinal walls usually attends this dilation, and is best marked in the rectum and sigmoid flexure. Pouches may form in the colon ; and an elongated sac tilled with n. or faeces forms a sort of hernial protrusion as the circular muscular fibres yield. These pouches are most common at the sigmoid flexure. "Ulcerations may arise from prolonged constipation ; perforation of the weakened wall and extravasation of the contents may lead to fatal peritoni- tis. Typhlitis and perityphlitis may arise from it. The colon and sigmoid flexure are altered in their position as well as in shape, their curvature > becoming more sharp than normal. Disease of the rectum and contiguous structure turia me*, abscesses about the rectum, fistula, anal Assures, stricture, prola] of the prostate gland and the bladder, passive hypera inia of the pelvic vis- cera, all are frequently met with in advanced life, and are in most instances clearly assignable to fecal accumulations, the result of habitual torpor of the bowels. With torpor of the rectum, there is sometimes a spurious diarrl acconrpanied by acute pain in the lower pari of the abdomen, by tenesmus and "bearing down" during defecation, and by the prefi Bcybalee in the foecea It may be accompanied by dysuria and even reten- tion. Heus and strangulated hernia have resulted from neglect of thi por, which maybe so complete that the relaxed and distended rectum, filled with hard f;eces, occupies nearly the whole pelvic cavil The accumulated faeces frequently form tumors at different points along the digestive tract, and in emaciated subjects are easily detected on | tion. They are often felt in the transverse or ascending colon as movable masses ; but the largest accumulations collect in the sigmoid riVxui caecum, where manual palpation in the left or right ileo-inguiual i\ readily discovers their size and sometimes their consistence. Differential diagnosis. — The differential diagnosis between spurious diar- rhoea (torpor of the rectum) and senile lientery I have already coi Prognosis. — You will have observed that, in the consideration of senile THE DISEASES OF OLD AGE. 253 constipation, all malignant growths, all mechanical interferences other than fecal, have been disregarded ; for when such are the causes, constipation is only a secondary symptom of a graver condition. Hence, if we regard constipation as a retention of fasces in -the lower part of the large intestine, the prognosis is very favorable, provided we can overcome the apathy and habitual indolence of the aged patient. Inflammatory complications are very grave ; fortunately, however, they are rare in the aged. Peritonitis, if it occurs, is always fatal. Treatment. — An old person should go to the water-closet at the same time every day, whether he has the inclination or not. The slightest call of nature must never be disregarded. Friction over the abdomen, or when the aged patient is confined to a chair, or is much debilitated, bending the body backward and forward will be found to provoke and aid defecation. The galvanic current over the abdomen, along the course of the large intestine, and to the anus, acts beneficially in many cases — the rationale of its action being the same as that of friction, rubbing, and kneading of the bowels. The diet should consist largely of vegetables, unless they are contrain- dicated. Prunes and figs are excellent gentle laxatives in the aged. Oatmeal, when it does not excite flatulence and heartburn, may be taken every morning with molasses instead of milk. A goblet of fresh cold water just before retiring or on rising will, in many cases, relieve a sluggish condition of the bowels, and a cigar or pipe after meals often has the same effect. But in many cases vegetables, oatmeal, fruit, smoking, all disagree with the patient, or are not efficacious, and then recourse must be had to medicinal agents. Many old people have taken first gentle, then stronger, and finally the most powerful aperients, with the belief that the bowels must move every day. In such cases you should call diet and exercise to your aid, and return to the milder laxatives, endeavoring to produce a healthy evacuation every other day. Tonics should always be combined with the laxatives ; indeed, many have gone so far as to regard strychnia, iron, or quinine, when given alone, as able to effect a radical cure in most cases. Colocynth, gentian, and quinine, is an excellent combination for a pill in mild cases. So also is a pill composed of aloes, rhubarb, and strychnia, or iron. Another efficient combination is aloes, myrrh, and gentian, com- bined with quinine, strychnia, or iron. Podophyllin often produces slow and painless evacuations, and deserves a careful trial in the treatment of senile constipation. In very obstinate cases the treatment may begin with the exhibition of the compound extract of colocynth, scammony, and about the sixth of a drop of croton-oil. One or two of such pills may be taken before dinner or at bedtime. These may be continued for a long time. Maclachlan records a case of a lady one hundred and three years old, who for the last fifty years of her life took a compound aloetic or rhubarb pill at bedtime. Brodie speaks of a gentleman, eightv-six years of age, "who for three-score years took an aloetic pill every night." The general rule in advanced life should be to use only mild laxatives, and to change them frequently ; the contin- ued use of drastic purges in old age is apt to lead to trouble. When colonic or caecal accumulations occur, active purgation is neces- sary ; at the same time the aged patient must be sustained by stimulants and nutritious food. 254 CLINICAL LECTURES ON When the lower part of the bowel is clogged, the mass will often have to be scooped out ; and, when very hard, this operation is best preceded by a steady stream of moderately hot water against the mass for about half an hour. Purgative enemata should be adjuvants to all forms of treatment, look- ing to the expulsion of a large mass that has been accumulating for a long period. A case is recorded in the " Cyclopaedia of Practical Medicine," of an old gentleman — paraplegic — who had a gallon of salt water thrown up every morning for a week after constipation of long duration. After several days an enormous mass of fasces passed, the activity of the muscular fibres having finally been called into play. I shall now briefly invite your attention to diseases of the bladder ; as we meet them in the aged, they are very different from those of adult life. Atony or Paralysis of the Bladder. Vesical paresis is frequently met with in the aged of both sexes ; it is essentially a condition of advanced age. In accordance with the plan I have adopted, a few words are nect 1 in regard to the changes which are normal to old age, and, at the time, different from those of adult life. Healthy old people secrete less urine than in middle life, and the color of the fluid is paler, less rich in solid constituents, and of lower specific gravity than normal adult urine. Epithelium from the various portions of the genito-urinary tract and mucus are usually quite abundantly mingled with it. The amount of urea secreted by very old men is small — only one hun- dred and twenty-five grains in twenty-four hours, being noticeaK than the amount in the urine of young children. The amount of uric acid is also diminished by about one-half. The quantity of urine discharged in old age averages sometimes as low as fifteen or twenty ounces per diem, and this is compatible with perfect (senile) good health ; but, when not more than six or eight are voided, the system soon indicates the presence of an abnormal quantity of urea. By atony or rmresis of the bladder is understood a lack of power in its muscular coat, by which its longitudinal and oblique muscular fibres and the detrusor urinaj do not contract, or only do so in a very tard; imperfect manner. Etiology. — In a limited sense, atony of the bladder is physiological in old age ; it is well known that the distance to which a boy can throw a stream of urine from his bladder is greater than that of an older person, and so the power of expelling the secretion goes on diminishing with ad- vancing years. There are two reasons for this : one is, that there is a steady loss of muscular power, a senile decay throughout the entire muscular system, the muscles losing their normal contractility ; and the other is, that the older the person, the more engaged in business care-; he will be, and hence, the calls of nature to void the bladder are very frequently and habitually unanswered. Thus, there is a certain degree of habitual distention of the bladder, not only during the day, but at night as well. This disregard to empty the bladder may be, as I have just said, voluu- THE DISEASES OF OLD AGE. 255 tary. Involuntary neglect occurs in prolonged alcoholic intoxication, and in all those diseases, whether acute or chronic, which affect the sensorium — among these may be mentioned small-pox, typhoid, typhus, paraplegia, apoplexy, epilepsy, and diseases of the spinal cord. Paralytic weakness of the bladder in old men is very frequently second- ary to an enlarged prostate ; and it may result, in either sex, from the individual being compelled to remain in a recumbent position a long time. Senile catarrh of the bladder may lead to subsequent paresis, from im- plication of the muscular coats in the process. Women who have had large families, and whose labors have been se- vere, are especially prone to palsy of the neck of the bladder ; the obese suffer oftener than those of the opposite condition. Paresis of the bladder, though common to both sexes, is more frequent in men from prostatic enlargement ; there seems, too, to be a predisposi- tion in some to atony of the bladder, and in them you will find such causes as passing from a heated room to the open air, or the slightest over-indul- gence at table, sufficient to induce temporary attacks of retention of urine. Finally the more impaired the general health, and the more sedentary the life of the individual, the greater the predisposition to atony of the bladder. Symptoms. — The bladder, unlike the rectum, retains its contents when paralyzed ; for the elasticity of the sphincter vesicae is inherent in the tis- sue itself. Thus retention occurs ; or, if the sphincter be involved also, we have a combination of incontinence and retention ; paradoxical as it may appear, only a part of the urine passes off, and that by its own gravity, aided, perhaps, somewhat by the action of the abdominal muscles, after a considerable quantity has accumulated in the bladder. The aged patient notices that there is a gradual diminution in the power of emptying the bladder ; that, after he wills to micturate, quite a time elapses before the first drops come, and that the act is more prolonged than usual, the urine falling perpendicularly and only becoming a full stream at about the middle of the act. The desire to micturate is now less often felt ; and if, when felt, it is disregarded, the desire soon disappears, as if the bladder had been emptied. The stream is feeble and interrupted ; occasionally the urine flows away either in drops or interruptedly, and the odor is usually disagree- able on account of its ammoniacal decomposition. This latter condition is generally the accompaniment of a paralyzed sphincter with vesical atony. After the patient thinks the act of urination is complete, a few drops will suddenly pass ; not infrequently those in advanced life have an escape of urine during the night. When the bladder has once become greatly distended, a considerable quantity of urine continues to dribble from it, the retention being still unrelieved. This retention with dribbling in old persons is a condition the true nature of which is frequently unrecognized. Cases have arisen where supposed tumors have been tapped, and a distended bladder entered, and a large amount of retained urine drawn off which was never suspected. In the very old the urine may steal away from the bladder as it flows drop by drop from the ureters. When retention is excessive the bladder slowly enlarges, finally rising up into the abdomen even as high as the umbilicus. 256 CLINICAL LECTURES ON On palpation, the distended bladder is felt round or pyriform in shape, hard, and elastic, projecting above the pubis ; over it you may detect fluc- tuation through the abdominal walls. Percussion elicits well-marked dulness, varying in extent with the amount of distention. If a condition which gives these physical signs is not relieved by the catheter, the aged patient will either have true incontinence following, the urine flowing away uninterruptedly; or there may develop urceniia, ammo- ncemia, intense catarrh of the bladder, or even vesical gangrene. In all cases the true condition of the bladder is readily determined by the introduction of the catheter ; and, in those advanced in life, and espe- cially when occupying a recumbent position, it may be necessary to press the hand over the bladder in order to expel the urine. Differential diagnosis. — Atony of the bladder in old age may be con- founded with retention from obstruction, and with ascites. In atony the urine will flow out slowly, or in faintly marked jets, in obe- dience to the respiratory acts, when the catheter is introduced, oftentimes pressure from without being necessary to expel it. In retention from ob- struction, the introduction of the catheter is attended with more or less difficulty at some point ; but, having once entered the bladder, a free stream is projected in a single jet. Ascites lias misled many from atonic retention, and some have tai the abdomen for dropsy. The introduction of the catheter is an unfailing means of diagnosis. Prognosis. — The results of not attending to atonic retention are various and grave. The constituents of the retained urine becoming absorbed, and the skin thus being charged with the extra duty of elimination of part of them, chronic eczema or some other form of intractable entail 'lion may occur, only to yield when the bladder is freed from all residual mine. Vesical catarrh, animonamia. anemia, and gangrene or sloughing of the bladder, are the complicating conditions which may ensue when tL has been of long standing. Complete recovery rarely occurs in these cases. The worst cases are those where paralysis and over-distent ion of the bladder have existed along time. In most of these case s. even when the bladder is regular 1 .; the patient is only relieved, not cured, tin b con- tinues, and, finally, comparatively rapid dissolution results. The prognosis becomes unfavorable when the patient has a rapid and feeble pulse, a furred tongue; when the appetite fails and the nigl. restless ; mental depression and final stupor supervenes. Death commonly occurs, in such cases, from exhaustion or urremia. Finally, the prognosis is influenced in a great measure by the age of the patient and the extent and duration of the atony. Treatment. — Old people cannot have it too thoroughly im] ipon them to empty the bladder directly the call of nature is felt. Thi- most important prophylactic measure. If the patient be an old invalid, he must assume a position on the knees when micturating, for otherwise the bladder is incompletely emptn Petit has recommended that in simple atony the patient should | the cold chamber firmly against the thighs and scrotum : or cold lotions, cold hip-baths and cold sponging may be resorted to. The catheter must be passed three or four times daily, so as : the muscular libres from any further distention. But do not \ THE DISEASES OF OLD AGE. 257 theterization so often that little urine shall collect in the bladder and in tins way convert the organ into a mere passage. The patient should learn to pass the instrument himself. If injections into the bladder are resorted to, the amount of fluid iniec- tions must not be more than four ounces at a time, and the temperature should be gradually lowered ; thus, the first injection should have a tem- perature of about ninety-four or ninety-five degrees Fahr., the second ninety degrees, and the third and last eighty-five degrees Fahr. If vesical catarrh exist, never inject an old person's bladder with cold water. Galvanic and electric currents are often of temporary service in senile atony of the bladder ; the powerful internal remedies that have been tried and found to act beneficially in certain cases, are strychnia, cantharides creosote, turpentine, and ergot. The general health of the patient should be carefully attended to ; for, without nutrition at a high standard, we cannot expect the muscular sys- tem, and this muscle as part of it, to regain, or at least to improve in its power. Hence, in most cases, iron, strychnia, the vegetable tonics and quinine, form a very important part of the treatment ; the bowels must be regulated with aloetic pills ; indeed, some claim that direct and permanent benefit fol- lows the use of aloes. Balsams, which are highly recommended, derange the already weak di- gestion of old age, and vesicants and embrocations possess little or no advantage. The urine may be made alkaline in some cases to prevent cys- titis, when this threatens. Finally, if there be constant dribbling, a portable urinal should be af- fixed, and the most scrupulous cleanliness enjoined. Of all the preparations of iron, the muriated tincture is the most serviceable. Closely connected with vesical paresis is Chronic Enlargement, Hypertrophy of the Prostate Gland. I use the term "chronic" enlargement to distinguish senile prostatic enlargement from that which may occur in adult life from inflammation. Enlargement of the prostate gland is by some regarded as a physiologi- cal condition in old age, while others state that it is a diseased condition incident chiefly to, but not wholly caused by old age. Morbid anatomy. — Prostatic hypertrophy may be general or partial, and is almost entirely confined to its muscular tissue, although the glandular substance may be slightly involved. Pathologically, this condition of the gland may be classed among myomata of the prostate ; when the glandular structure is implicated the name adeno-myoma is applicable. Cases are recorded where in very old men the gland had acquired the size of the two fists, or even that of a child's head, nearly filling the lower basin of the pelvis. But, when it reaches the size of an orange, it may be regarded as exceptionally large, as it is generally about the size of a hen's egg- The color, externally, is unaltered. The so-called third lobe is fre- quently involved, and may acquire the size of a hickory-nut the remaining portion of the gland being unimplicated; this is called median centric hyper- trophy. When lateral hypertrophy exists, it is rare to find one lobe affected to the exclusion of its fellow. The tumor in general hypertrophy may be smooth, rounded, and regu- 17 " 258 CLINICAL LECTURES ON lar, but it is rather the rule for unsymmetrical enlargements to be present, the gland presenting great irregularity of outline. Cases are recorded where it has weighed twenty ounces. On section the cut surface pushes up above the level of the cut, and the alternations in color are more strikingly marked than in adult life. A viscid fluid, the thickened prostatic secretion, sometimes fills the acini and may be mistaken for pus. In many cases there is no fluid whatever in the gland. In the centre of the mass you will frequently find numerous small, dense fibrous tumors, rarely exceeding the size of a pea. Prostatic con- cretions or calculi are also very frequent accompaniments of this condition, and are found in the interior of the glandular acini or ducts. These are round, colorless masses, varying in size from <> 1 <6 of an inch to ^V of an inch in diameter, and resembling colloid material in their action with tinc- ture of iodine and sulphuric acid. Larger calculi are sometimes found in hypertrophied prostates, consisting of lamina? of oxalate or phosphate of lime, very difficult to crush. In some instances, pedunculated hypertrophic prostates are found, which surround the neck of the bladder like a collar. The veins of the gland are found dilated and tortuous. The urethral canal is in nearly all cases more or less implicated. When lateral hypertrophy predominates, it is twisted ; and when the middle lobe is chiefly enlarged, it is flattened and compressed. The prostatic portion of the canal is always elongated and expanded, so that it may become capable of holding two or three ounces of urine. This elongation also carries the neck of the bladder upward and behind the pubes. Etiology. — Old age is an essential condition for prostatic enlargement. Its exact etiological relationship with aortic insufficiency, or with chronic pulmonary affections, is not yet definitely determined. The condition is rare before fifty, and quite an exceptional circum- stance before sixty ; subsequently it is of quite frequent occurrence. Sir Benjamin Brodie used to say : " When the hair becomes gray and scanty, when specks of earthy matter begin to be deposited in the tunics of the arteries, and when a white zone is formed at the margin of the cornea, at this period the prostate gland usually, I might say, perhaps, in- variably, becomes increased in size." Sir Astley Cooper even went so far as to regard hypertrophy of the | tate as a salutary process, since " it prevents incontinence of urine, which in the aged would almost always take place were it not for this preventive." Sedentary habits, over-indulgence in venery, the contrary state of affairs, gout, high living, hard riding (as in cavalrymen), all these have been signed as causative conditions for an enlarged prostate, but 1. :orv proof exists to substantiate the assertions. One peculiar point, which it may not be out of place to mention, is that organic stricture of the urethra and enlarged prostate are among the rarest coincidences of advanced life. THE DISEASES OF OLD AGE. 259 LECTURE XXXI. SENILE HYPERTROPHY OF THE PROSTATE GLAND. Summary. —Symptoms— Differential Diagnosis— Prognosis— Treatment. Ammonsemia— Definition— Morbid Anatomy— Etiology— Symptoms— Differen- tial Diagnosis — Prognosis — Treatment. Gentlemen :— At my last lecture I spoke of the etiology of senile en- largement of the prostate gland ; we shall now turn to a consideration of its symptoms. Symptoms. — Prostatic enlargement may exist for a long time to a limited extent without producing any symptoms that direct attention to the genito- urinary tract. A case is recorded where, at the autopsy of a man who died of old age at one hundred and one, the organs were all normal (at the senile standard), except the prostate, which was exceedingly hypertrophied, and no symptom of its presence existed during life. If this condition induce a "bar at the neck of the bladder," there may be retention of urine ; there is always in such a condition more or less residual urine in the bladder. The increased mucous secretion from the hyperaemic part, mingling with the stagnant urine, aids greatly in its decomposition ; and the carbonate of ammonia thus set free increases the inflammation and induces retention, and thus distention of the bladder is a constant result of an enlarged pros- tatic gland. In the mildest form of chronic enlargement, the old man notices that he micturates oftener during the day than he used to, and that he has to rise a little earlier in the morning on account of a pressing desire to urinate. There is a sense of uneasiness, or actual pain of a stinging kind, extending along the penis, felt more especially at the glans. He has to wait a little time before the flow begins, and more or less straining is always necessary to start it ; then it comes slowly and cannot be projected in a jet ; indeed, it usually falls nearly perpendicularly from the urethra. After he thinks the act complete, several drops pass ; and in care- less old men, especially in summer, this is more inconvenient to others than to themselves. The stream is always small. After a time he is compelled to evacuate the bladder every hour or two, or there may be a continual dribbling, especially marked when the pa- tient is in a recumbent posture. There is no sense of satisfaction after micturition ; and just here it may be mentioned that, when excessive prostatic enlargement exists, there is a sense of incomplete evacuation of the rectum, and tenesmus is occa- sionally present at stool. For the same reason, hemorrhoids and prolapsus ani are by no means infrequent coexisting conditions. Any slight indiscretion in eating and drinking may bring on an attack 200 CLINICAL LECTURES OX of retention. All -violent or jolting exercise, such as horseback-riding, in- creases the desire to micturate, and may cause slight pain along the course of the urethra, together -with flying pains in the hips, limbs, and about the pubis. The irritation from an enlarged prostate often excites such lascivious desires in old men that they become notoriously indecent. Such cases are common everywhere ; in every village there are one or two old men who are terrors to the maidens. In the severer form, the bladder is exceedingly irritable ; a sense of weight and fulness is experienced in the perina?um ; retention soon fol- lows, the other symptoms being those of the milder variety. The efforts made to expel the urine are often so severe that various por- tions of the mucous membrane, weaker than the rest, are pressed out, and sacculation of the bladder is the result. The urine decomposing in these sacs is one of the most favorable con- ditions for the formation of stone. When the outflow has been obstructed for some time, structural cbai occur in the muscular and mucous coats of the bladder ; there is usually a mild or severe chronic catarrh of the ureters and calices and pelvis of the kidney. Sometimes the bladder hypertrop hies and contracts, instead of becom- ing distended ; then irritability of the bladder becomes u marked and con- stant symptom. As the disease progresses, and when the mucous nienibrane is inflamed and ulcerated, the urine scanty and containing blood and jnis. the coun- tenance becomes sallow and indicative of organic disease. Finally, worn out by sleepless nights and continual pain, the aged suf- ferer sinks from exhaustion, retaining his faculties till the last ; or he dies more rapidly in a coma which was preceded by typhoid symptoms — a dry. brown tongue, general prostration, rapid, feeble, and irregular pulse, and low, muttering delirium. The urine may be alkaline or acid. The first changes in it are a fetid smell, and the presence in the m tion of viscid, string}' mucus. As the disease progresses, more and more of residual urine is left in the bladder, and we find it dark and mingled with gummy mucus. "SVhen vesical catarrh is present, the urine may have an almost milky appearance, from admixture of pus, and a horribly fetid and ammoniacal odor, blackening the silver catheter. It is rare to find the urine of an old man with enlarged prostate that does not contain pus-globules, blood-corpuscles, amorphous urates and phosphates, mingled with crystals of the triple phosphates and stringy mucus. A physical examination per rectum discloses a rounded or nodul lobular, dense tumor, in the region of the prostate gland. Pressure upon this tumor will usually excite a desire to urinate. Percussion may reveal an enlarged bladder. The catheter cannot be easily introduced into the bladder, on account of the obstruction it meets from the enlarged gland. In the attempt to explore the urethra a gum-elastic catheter should be used ; and if. in en- deavoring to make a diagnosis by catheterization, there is much difficulty and any doubt, Squire's vertebrated catheter, or the soft, bulbous-pointed prostatic catheter, is probably preferable to any other instrument can turn very abrupt curves. Besides, there are multitudes of instruments whicli it is unnecessary to enumerate for diagnosticating the amour.: situation of the urethral twisting and narrowing which come from hyper- trophy of the prostate. THE DISEASES OF OLD AGE. L>01 Differential diagnosis. — Senile prostatic enlargement may be mistaken for atony of the bladder, stricture of the urethra, and stone in the blad- der. Atony is readily diagnosed from hypertrophy of the prostate by the manner in which the urine flows from a catheter. In enlargement of the prostate the flow is quite forcible, and can often be made more so by the patient's will ; whereas in atony of the bladder the urine merely flows out from the instrument, and no augmentation can be voluntarily made in its force by the patient. Stricture is not a disease of advanced life. In stricture there are no rectal evidences of a tumor on physical exploration, while these are present in hypertrophy of the prostate. In stricture there is usually a history of venereal disease, which may be absent in hypertrophy. A sense of incom- plete evacuation of the bladder is present in cases of prostatic enlarge- ment, and absent when organic stricture alone is present. The urine in stricture is normal, while in enlargement of the prostate it has the abnormal ingredients which I have just described. Again, the catheter meets an obstruction about six inches from the meatus in stricture ; and in enlargement of the prostate the distance of the obstruction is at least seven inches from the meatus. Stone is very difficult of recognition, as contradistinguished from a hypertrophied prostate. When blood is passed after exercise, it indicates the presence of a stone, and in the latter condition the difficulty in micturition has been as long and as steadily coming on as in enlarged prostate. The tumor in stone, if felt per rectum, is movable ; while it is immov- able in prostatic hypertrophy. The sound is the only means which we have of making a positive diagnosis. Prognosis. — We cannot cure enlargement of the prostate in old age, nor can we check its progress when once it is developed ; it is unquestionably a part of senile decay. Its duration, then, is indefinite. The outlook for comfort is best in those cases where there has never been complete reten- tion of urine. The effects of an enlarged prostate in the aged vary greatly, and neces- sarily modify the prognosis. A moderate enlargement of the " third " lobe, or of one or both of the lateral lobes is sometimes attended by retention of the urine and great difficulty in passing the catheter ; while cases where the autopsy has revealed a prostate as large as a base-ball had caused dur- ing life no difficulty with the urine and no obstruction to the passage of a catheter. This condition may become very grave from the complicating conditions which are rarely altogether absent during its course ; these are cystitis, pericystitis, vesical ulceration, overflow, inflammation of the ureters, pyeli- tis, nephritis, perinephritis, enlargement of the testicle, hemorrhoids, pro- lapsus ani, and ammonsemia. Treatment— We have no means of arresting the slowly advancing chronic enlargement of the prostate gland in advancing life. If anything will check its progress, it is a diet and mode of life which are the opposite to those which are known to favor rapid and extensive hypertrophy. ...,,, •* Alcohol, if used, must be used moderately, or it is better not to use it at all. The slightest call of nature to evacuate the bladder must be imme- diately obeyed. Horseback-riding is to be avoided. Flannels must be worn next the skin, the extremities especially being kept warm. 262 CLINICAL LECTURES ON Ultimately the regular daily introduction of the catheter will become a necessity. As a rule, old men are yery much opposed to the introduction of an instrument into their bladders, and it may require much persuasion and a clear description of the exact state of affairs before they will permit it. Again, it is to be remembered that catheterism is sometimes dangerous in old men ; the following statements will tell } r ou at once not only to post- pone their use as long as possible, but it will also indicate to you the im- portance of gentleness and care in the manipulation : An old man, eighty, has been troubled with some difficulty in passing water. A bougie is passed carefully till it reaches the prostate, when it stops. It is then withdrawn, for no force is used to push it farther, and a little blood follows its removal After that day not a drop of urine passes except through the catheter. Another case resembles this precisely, except that, following the few drops of blood, there is complete retention, which results in death in a few days. The shock from a cold sound [wring over the prostate, even when slightly hypertrophied, may give rise to urgent symptoms, and has v death. Still a catheter must be introduced, and when introduced should be of the temperature of the body, the patient always standing during the operation. The bladder is to be emptied at least twice a day ; and if thei • tis, glycerine or biborate of soda may be added to the water used to wash out the viscus. Alkalies, administered witli flaxseed tea, are very good internal n dies when the urine is strongly acid. During warm weather, old men may not require the catheter ; In. soon as cold weather approaches, it will be necessary ngain. Retention and catarrh of the bladder demand prompt and appro}'! treatment, for in old age they rapidly bring <>n a condition which may end iu death. Ambon jeha. In connection with enlarged prostate and atony of the bladder, e the consideration of a disease which, though rare during adult life, is fri - quently met with in those advanced in life. Ammomemia is that change in the blood due to the presence of bonate of ammonia, which arises from metamorphosis of urea, the result of retention of the urine in the urinary organs. Thus it is evident why arnmonaniia is frequent in old age. for in that period of life atony of the bladder and enlarged prostate are frequent con- ditions. Morbid anatomy. — The urinary tract will present the appearance of Inore or less acute catarrh, as well as conditions favoring or causing urinary accumulations. There is always chronic catarrh in the intestines, and it has been ob- served that they were rilled with a greenish yellow mucus and an alkaline rluid, having an ammoniacal odor. Ulcers have also been found in the large \w: niilar to dvsenterv. THE DISEASES OF OLD AGE. 263 It may be mentioned here that in the cases where ammonsemia occurs with uraemia, which is quite rare in the aged, it is possible for the urea excreted into the intestines to change into carbonate of ammonia, and thus bring about the pathological condition I have just described as sometimes existing. Rosenstein denies any connection between ammonseniia and poisoning by carbonate of ammonia, but the weight of opinion is against his state- ment. Etiology.— All that is required to produce ammonsemia is the retention of urine in the body sufficiently long to allow of the metamorphosis of its urea. Decomposition occurs very quickly, and of course, more rapidly in, than out of the organism, on account of the bodily warmth. Ammonsemia occurs with enlarged prostate, atony, and paralysis of the bladder. These are the chief causes in old age, although it may arise at that period from stricture of the urethra, sacculated kidney, pyonephrosis, and hydronephrosis. Symptoms. — Ammonsemia may be divided into two forms, according as the inducing cause is of sudden but permanent occurrence, or comes on gradually and steadily. In the first, the so-called "acute" form, there are nausea and vomit- ing, intermittent chills, acceleration of the pulse-rate, followed by a rise in temperature. Diarrhoea is also a frequent accompaniment of acute ammonaemia. The complexion rapidly becomes dingy and bronzed ; and there is great muscular weakness, with a tendency to lethargy and stupor. Rarely, however, are there any convulsions or oedema of the feet. The tongue is brown, dry, and shining — the " beefy tongue ; " the mu- cous membranes are remarkably dry, that of the throat especially ; and the perspiration and breath have a well-marked ammoniacal odor. In the "chronic" form, that which comes on in old men with enlarged prostates or atonied bladders, the complexion gradually passes from a sal- low to a dingy brown hue, and there is slow, but progressive ema- ciation. The aged patient is restless, has a slight headache, and insomnia be- comes a very distressing symptom. Now and then chills occur, but with no regularity, and vomiting is an important symptom. Meanwhile, as the complexion darkens and emaciation progresses, the mucous membranes begin to assume a dry, glazed, shining look, the skin becomes drier and drier, and the breath and perspiration take on a distinctly ammoniacal smell, but the amount of perspiration is greatly diminished. The temperature in these prolonged cases is constantly above the nor- mal ; and as the condition gets worse, the pulse is each day more and more accelerated. With these symptoms there will be no oedema of the feet, or, in the majority of cases, convulsions ; but the symptoms will rather counterfeit, to a very striking degree, those of chronic gastric catarrh. Persistent vomiting is often a prominent symptom. The bowels are usually consti- pated, although at times slight attacks of diarrhoea alternate with the con- stipation. Finally, after emaciation has become extreme, and a cachexia has been fully developed, the restlessness and insomnia give way to lethargy, stupor, and the patient passes into a typhoid condition. In old men with enlarged prostates this is quite a common termination. 264 CLINICAL LECTURES ON the patient passing from stupor into the comatose state, with low, muttering delirium, rapid, feeble, and irregular pulse, and finally dying in a condition of deep coma. The urine is ammoniacal, and hence strongly alkaline wJien passed, fre- quently containing pus and depositing amorphous phosphate of lime with crystals of ammonio-magnesia phosphate. Its odor is as offensive as it is pungent. Differential diagnosis. — Senile ammomemia may be confounded with " typhoid gastritis," pyremia, and septicaemia. In typhoid gastritis the urinary symptoms are negative, in ammonaemia they are diagnostic. In gastric catarrh there is no particular odor to the breath or perspira- tion, while this is markedly ammoniacal in cases of ammoniacal poisoning. Nausea and vomiting may be prominent symptoms in chronic ammon- temia (the only form which would lead to confusion), while they are very slight or absent in gastric catarrh. In the amnionsemiaof the aged, the catheter or a rectal examination will show the existence usually of atony of the bladder, or hypertrophy of the prostate, while you will find no genito-urinary causes in typhoid gastritis. Pyaemia and aepticcemia may be mistaken for ammonamia, on account of the color of the skin and lethargic expression of the face. JnpyCBmia there is the history of a severe initiatory chill, profuse recur- ring sweats, high temperature — 102 to 104° — sweet, sicky breath, and an appearance of infarctions, thrombi, or multiple abscesses in some organ. None of these symptoms occur in ammonamiia; on the contrary, the odor of the breath, the condition of the urine, and the evidence of some me- chanical obstruction, would all be present, and with the other points would suffice to establish the diagn In septicemia the temperature is much higher (105 — 1<»7 ) from the onset; there are no recurring chills, no ammoniacal odor to the breath or body, and no urinary evidences such us are found with ammoniemia. And finally, in both pyaemia and septicemia the skin is in a strikingly opposite state to that of ainmonamia. being for the most of the time bathed in a copious perspiration, while in the la: Iry. harsh, and has an ammoniacal odor. Prognosis. — The prognosis in ammonamia ia determined to a great ex- tent by the conditions which cause it AYhen their removal is possible— as in retention of mine from enbu prostate — the prognosis is favorable. When it is due to pyelitis or sacculated kidneys, it is very bad : in all cases there is a gradual and steady impoverishment of the general health ; old people suffering from any blood-poison are liable to sink rapidly into a typhoid state if the conditions which give rise to the poisoning cannot be speedily removed. Treatment. — Its treatment consists in removing r sible in a large proportion of cases, since atony of the bladder and hyp* phied prostate are by far the most frequent conditions. Very often, when the aged patient seems fatally sinking, and when no suspicions have been attached to the bladder, you may draw off a barge quantity of stinking urine, and then, with subsequent washing of the viscus, a rapid improvement takes place, and the gastric symptoms subside. The diet of this class of patients should always be supporting and stim- ulating. Atony of the bladder and hypertrophy of the prostate must be fan THE DISEASES OF OLD AGE. 2G5 according to the rules already given, and the catheter will here be most useful, and should be passed at least twice every day. To the tepid water used to wash out the bladder, you may add, at dis : cretion, carbolic acid, biborate of soda, or glycerine. The w T ashings should be continued until the withdrawn fluid is per- fectly clear and inoffensive in odor. The treatment of this condition, beyond the removal of the cause, re- solves itself into supporting and nourishing the patient, and relieving those catarrhal inflammations which have been excited by the ammoniacul poi- soning. Fig.l ■■ Fig. 2. Plate I Fig. 3. Fig. 4 Fig \ DESCRIPTION OF PLATES. PLATE I Fig. 1. — Right hand of a man sixty-nine years old, attacked with gout since his thirty-third year. A large tophus is seen at the base of the index-finger, on a level with the metacarpo-phalangeal articulation. A second tophus, smaller than the preceding, is situated at the base of the middle finger. There are nu- merous concretions of urate of soda upon the external ear of this man. Fig. 2. — Left hand of a gouty woman, eighty-four years old, who died in the Ralpetriere, in 1863. Both hands were symmetrically" affected, and to the same degree ; there was no appearance of tophaceous concretions in the vicinity of the joints. Here we find an exact reproduction of one of the types of deformi- ties of the upper extremities most frequently seen in progressive chronic articular rheumatism. The articular cartilages of the metacarpo-phalangeal articulation were encrusted with urate of soda. Upon the dorsal aspect of the metacarpal heads there were, besides, tophaceous deposits which, situated immediately beneath the skin, and pressed against the heads of the bones, were flattened, forming no appreciable projection upon the back of the hand ; this occurred in such a way that, before dissection, their existence could not be recognized. Pegs. 3, 4, 5, and 6. — These refer to the anatomy of Heberden's nodes. In Fig. 3 the second phalangeal articulation is seen deformed, but still covered by the soft parts. The pisiform projections described by Heberden are well marked. Fig. 4 shows the ends of the bones laid bare by dissection; the articular surfaces are broadened in all directions and thickened, on account of the forma- tion of osteophytes. Fig. 5. — The same preparation viewed laterally. F IG . 6. — Normal condition, with which Fig. 4 is to be compared. PLATE E. Figs. 1 and 2. — Deformity of the hands in general chronic articular rheuma- tism. The characteristics of the first type are well shown in Fig. 2. Fig. 1 gives a good idea of the deformities occurring in the second type. Fig. 3. — Changes in the mitral valve in a case of primitive general chronic articular rheumatism. Fill- Plate II Fig. 2 Fig. 3. Bf @ F*2. Att Plate IE. Fig. 3. Fig. 4. in Fig- 5- PLATE m. Fig. I.— Gouty nephritis.— -Part of a section of the kidney (10 diameters) ; the white, chalky-looking lines (a) are deposits of nrate of soda occupying the medullary (tubular) substance. These are represented in Fig. 3, magnified 150 diameters. Fig. 2. — A convoluted uriniferous tubule of the cortical substance, whose epithelial cells (b), large and clouded, are also filled with fatty granulations. (300 diameters.) Fig. 3. — Crystals of urate of soda (d), forming the deposit in Fig. 1 (a), visi- ble to the naked eye. (Section of the tubular portion, 150 diameters.) Fig. 4. — This figure has reference to the period of dissolution of these de- posits under the influence of acetic acid. The free crystals are dissolved, and nothing remains but an amorphous deposit (e), which slowly goes on dissolving. It is then very clearly seen that a portion of this deposit is situated in the inte- rior of the uriniferous tubules (g). (Section of kidney, 200 diameters.) Fig. 5. — Synovial fringes from the knee-joint covered with their epithelium, and exhibiting at (m) a deposit of urate of soda, generally amorphous. (N. B. — These different preparations are from a gouty woman eighty-four years old, who died in the Salpetriere, in 1863, and whose right hand is pictured in Fig. 2 of Plate I.) -pio. 6. — L e ft ear of I. M , an old coachman, born in Poland in 1807, and in whom the first attack of gout occurred at the age of twenty-five. [Hopital Rothschild; service of Dr. Worms.) h, h, h. — Large concretions of urate of soda. These tophi, so the patient says, commenced to appear three years after the first attack of articular gout. INDEX. Abscess, atheromatous, 22, 23 pulmonary, symptoms of, 203 Acid, lithic, discovery of, 95 Acid, uric, amount of, in gout, 42 discovery of, 41, 1)5 proportion of, in gout, 41 Adams, 101, 104, 143, 144 Affections, chronic, 10 Alcoholic intoxication, and apoplexy, dif- ferential diagnosis of, 234 and cerebral hemorrhage, differential diagnosis of, 234 Alcoholismus, chronic, in animals, 14 Aldrovini, 53 Algidity, central, 184 drugs which produce, 180 experiments in the production of, 187 in cardiac diseases, 189 in endocarditis, 189 in pericarditis, 189 in peritonitis, 190 in pleurisy, 190 in pneumothorax, 190 semeiotic value of, 37 Ammonaemia and pysemia, differential diagnosis of, 264 and septicaemia, differential diagnosis of, 2(54 typhoid gastritis, differential diagno- sis of, 264 Ammonaemia, 262 differential diagnosis of, 264 < etiology of, 263 morbid anatomy of, 262, 263 prognosis of, 264 symptoms of, 263, 264 treatment of, 264, 265 Anaemia, algidity in, 185 senile. 224 Anatomy, of ancients, 6 modern, 8, 9, 10 pathological limit of, 9 senile, 20 "the dead," 10 the new, 10 Ancients and modems, comparison be- tween, 8-10 Andral. 121 Angina, in the gouty, 74 pectoris and asthma, differential diag- nosis of, 2L9 Ankylosis, 47 Anoxaemia, 172 x\nthrax, uric acid, 73 Antagonisms, doctrine of, 75 Aorta, atheroma of, 51 Aphasia a symptom of gout, 67 Apoplexie foudroyante, 233 Apoplexy, 231 and alcoholic intoxication, differential diagnosis of, 234 and cerebral congestion, differential diagnosis of, 234 and embolism, differential diagnosis of, 234 and uraemia, differential diagnosis of, 234 differential diagnosis of, 234 etiology of, 232 morbid anatomy of, 231, 232 prognosis of, 234, 235 rheumatic, 67 symptoms of, 232-234 treatment of, 235 Appendix to Lecture IX., 92 Arcus senilis, 66, 228 Arfwedson, 160 Arteritis deformans senile, 224 Arthritides, 71 Arthritis, chronic rheumatismal, character- istics of, 105 histological study of, 106 Arthritis deformans, 143 characteristics of, 144 Arthritis, from prolonged rest, 112 fungous, 112 pauperum, 19 rheumatoid, 101 scrofulous, 112 Arthrocace senile, 145 Arthropathies, gouty, 113 secondary, 113 symptoms of, in acute articular rheu- matism, 117 tertiary, 113 Articulations in gout, 45 INDEX. Ascites and paralysis of the bladder, dif- ferential diagnosis of, 250 Asthma and angina pectoris, differential diagnosis of, 219 and bronchitis, differential diagnosis of, 219 and emphysema, differential diagnosis of, 219 and laryngeal spasm, differential diag- nosis of, 219 and pericarditis, differential diagnosis of, 219 and pulmonary oedema, differential diagnosis of, 219 Asthma, 21(5 4 'cardiac," 217 differential diagnosis of, 9 1 B etiology of, 216 gouty, 08 • nature of, 216 'peptic," 216 physical signs of, 218. 21!) prognosis of, 22(1 symptoms of, 2 Hi treatment of, 220, I Atheroma, 221 Atrophy, cerebral, 848 differentia) diagnosis of, 211 etiology of, MO morbid anatomy of, 210 prognosis of, 247 symptoms of. 210 treatment of. 211 Auduran's wine. 157 Aurelianus. (Julius. 80 Auscultation, modifications of, in old age, 204 Autenrieth, 18 Auto- toxaemia, 172 Babington, 113 Bacon, L2 Baglivi, 18 BaiUarger, 87 Baillou. 89 Hal four Ball, 78 Bamberger, 129 Banish," 164 liarensprung, 30 Bartek Basham, 69 liastien, 21 Beyle, 8 Baynard, 122 iiazin, 71, 133 Beau, 20. 81. 140, 164 lVequerel, 121 Beers, English, 02 Begbie, H>4 Bence-.Tones. 51, 75, 98 Benek< Bennett, 8S Bergmenn, 187 Bernard, Claude, 3, 13, 70, 100. 174, 190 I Bibra, 22 ' Bichat, 3 | Billroth, 182, 186, 187 Biology in medicine, 4 Bird, 43 Bocker, 141, 158 experiments of, 98, 141. 168 i Boerhaave, 4, 29, 81, 173, 174 Bonnet, 112 Borden, 4 Bouillard, 30, 110, 121. 124, 129 Boyer. 118 Bladder, atony of, 254 and hypertrophy of the prostat. . dif- ferential diagnosis of, 201 Bladder, in gout. irritable, in gout, 09 Bladder, paralysis of, 2">4 and ascites, differential diagm 856 and retention of urine, differential diagnosis of, S differential diagnosi- etiology. 254, . prog symi treatment Bladder, stone in, and hypertrophy of the prostate, differential diagnosis of, . Blagden and Dobson. experiments o: Blood, changes in, in old age, 224 of, in gout, 43 Bramson. 51 Brand, 175 lea, 188 Briuton, 86 Broadhurst 104 Bro<: Bronchiecta- d signs of. Bronchitis, capillary, and pneumonia, dif- ferential diagru Bronchitis, chronic. J differential diagnosis of. etiol< \ morbid anatomy of. 209. 210 physical signs of, 21 . prognosis of, 21:?. 214 symptoms of. 210. 212 treatment Bronchitis, chronic, and asthma, difT- tial diagm « and phthisis, differential diagno>> 813 Bronchorrhaa. 211. 212 Broussais. 3. 11 Brown-S. quard. ■. Bucquov. M Budd, 60, 04. 66, 86, Burrow Caldwell. 28 Calliburees. 174 Calorification, inhibit Cancer, algid INDEX, 273 Cancer and gout, 80 Canstatt, 120 Cardiopathies, rheumatic, septicaemia in, 128 Carditis, polypoid, 124 Carinichael, 72, 73 Cartilage, articular, in gout, 45 Cartilage, changes of, in chronic rheuma- tism, 10b* Cartilage, diarthrodial, in gout, 45 Cartilages in abarticular gout, 70 incrustation of, 47 Cart wright. 159 Castro, Koderic a, 61 Catarrh, chronic bronchial, differential diagnosis of, 213 etiology of, 210 morbid anatomy of, 209, 210 physical signs of, 212, 213 prognosis of, 213, 214 symptoms of, 210, 212 treatment of, 214, 215 Catarrh, chronic bronchial, and phthisis, differential diagnosis of, 213 Catarrh, ''dry," 211 Catarrh, gastric, anorexia as a symptom of, 243 differential diagnosis of, 244 etiology of, 242, 243 flatulence as a symptom of. 243 heart-burn as a symptom of, 243 morbid anatomy of, 241, 242 prognosis of, 245 pyrosis as a symptom of, 243 symptoms of, 243, 244 treatment of, 245, 247 Catarrh, gastric, and atonic dyspepsia, dif- ferential diagnosis of, 244 Catarrh of the bronchi, senile, 201) pituitous, 211 senile gastric, 211 Cazalis, 80 Cephalalgias, gouty, 07 Chalk-stones, 46 Changes, local, in gout, 45 Chegoin, H. de, 6Q Chelius, 158 Cheyne-Stokes dyspnoea, 228 Chill in old age, 31 Cholera, 37 Asiatic, algidity in, 181 Chomel, 104, 121, 149, 153 Civiale, 70 Clin, 60 Cloetta, 97 Cnidian school, 6 Colchicum, in the treatment of gout, 157 physiological effects of, 158 Cold, death from, 175 Colly, 84 Collapse, 191, 192 in malaria-poisoning, 193 in small pox, 193 in the plague, 193 in typhus fever, 193 in yellow fever, 193 18 I Colles, 101, 104, 145 Colombel, 144 Congestion, rheumatic pulmonary, 131 Conjunctivitis, rheumatic, 133 Constipation, senile, 250 differential diagnosis of, 252 etiology of, 250 prognosis of, 252, 253 symptoms of, 250 treatment of, 253, 254 Constitutions, medical, doctrine of. 6 Contractions, muscular, cause of deformity in nodular rheumatism. 140 Convulsions, a symptom of gout, 67 a symptom of rheumatism, 67 Cooper, Astley, 258 Copland, 117 Cornil, 105, 133 Corpuscles, Gluge's, 236 Corradi, 84, 85 Corvisart, 3 Cos, school of, 6 Crises, theory of, 7 Cruveilhier, 9, 19, 41, 49 Cullen, 64 Darembf/rg, 5 Daubenton, 23 Davy, 53 Day, 20 De Castelnau, 51 Dechamps, 69 De Haen, 30, 167 Delle-Chiaje, K4, 149 De Martini, 43 De Mussy, Gueneau, 164 Derangemeuts, functional, 11 De Rennes. 159 Deville, 104 Diabetes. 27 algidity in, 185 Diabetes and gout, 75 Diabetes, metastatic, 75 symptomatic, 75 Diarrhoea, senile, 247 differential diagnosis of, 248 etiology of, 247 prognosis of, 248 symptoms of, 247, 248 treatment of, 248, 250 Diatheses, 8 gouty, influence of, 44 Dietrich, 50 Digestion, physiology of, in old age, 241 Dilatation, cardiac, and fatty heart, differ- ential diagnosis of. 229 Disease, ancient views of, 3 Diseases, acute and chronic, distinction between, 8 constitutional conception of, 8 Diseases, febrile, of the continued type, 177 of the intermittent type, 178 of the remittent type, 178 Diseases, latent, 27, 28 in old age, 27 274 INDEX. Diseases of old age, general characteristics of, 18 Diseases, peculiarity of, in old age, 24 special, of old age, 24 with subnormal temperature, 37 Dundas, 85 Durand-Fardel, 19 Dyspepsia, 244 atonic, and catarrh of the stomach, differential diagnosis of, 244 follicular, 241 gouty, 52 Ear, diseases of, in abarticular gout, 71 Eczema, 133 in gout, 70 Edwards, 51 Embolism and apoplexy, differential diag- nosis of, 234 Embolism and hemorrhage, cerebral, dif- ferential diagnosis of, 234 Embolism, experimental, 13 Emphysema and asthma, differential diag- nosis of, 219 Encephalomalachia, 336 Encephalopathy, rheumatic, 132 Endocarditis, 124 arterial emboli in, l'J7 capillary emboli in, 127 capillary embolism of kidnev in. 128 liver in, 128 pathology of. 125 splenic embolism in. 128 Endocardium, histology of. 133 ESngel, 75 Environment, theory of, Epilepsv, essential rise in temperature in, 171) Erasmus, 78 Erb, L83 Erysipelas, 81 in the gouty, 73. 74 Erythema nodosum, 153 Faber, C6 Falconer, 90 Fatalism, geographical, G Fever, characteristics of, in rid ago. 89 Fever, definition of, 29 in old age. 86 intermittent. 31 phenomena of. 89 rheumatic. 117 symptomatic intermittent theory of, 178 thermometry in. 90 traumatic experiment;!!. E> Fevers, in old age, 24 malarial, 178 Fibrous tissue in abartieular gcut, 70 Fischer, 180 Fisher, 18, 75 Floyer, 18 Forbes, Murray, 41, 95 Fourcault and Edenhuisen, experiments of, 174 Frolich, 186 Fuller, 84, 101, 110, 119, 120, 122, 132, 133, 150, 155, 164 Funke, 11 Galen, 29, 61 Gallois. 78 Gangrene, dry, in the gouty, 73 pulmonary, symptoms of, 203 senile, of extremities. 83 Garrod, 41, 42, 43, 49, 51, 52. 57. 59, 60, 63, 65, 66, 68, 69, to. 71, 73, '.mi. 100, 101, 117, 132, 133, 150, 153, 154, 158. 160, 164 Gastritis, catarrhal. 241 Gastritis, typhoid and ammonaemia, dif- ferential diagnosis of, 264 Gavarret. 30, 121 Geist, 2ii, 23 Generative functions in old age, 23 Geuth. 05 Gerhardt, 175 Germany, physical diagnosis in, 15 Gillette, 28 Glands, salivary changes in, in old age, 241 Glycosuria, experimental, 13 Gorget, 1 1 Goupil. 159 Gout, abarticular, 70 action of certain drugs in. 74 Gout, u deviations from regular type of diseases of the intervals. 41 • xysm. 41 functional derangements in, 41 general, 40 local symptoms of, 5 parti;. primitive general. 57 prodromata of, 55* regular type of. 57 symptoms of, 56 Gout, age in the causes of, V T alcoholic beverages as causes of, 91 alkalies in the tieatmeut of, 160 alternating. 40 ammoniated tincture of guaiacum in the treatment of. analytical study of the causes i anomalous treatment of, 163 antiquity i at on blisters in the treatment of. I cerebral symptoms of, and d< tremens. characteristics of new attacks ( Gout, chronic. 40, 58-60 attacks in. 41 characteristics of. 59 permanent lesions in. 41 Gcut. climate in the ce INDEX. Gout, colchicum in the treatment of, 157 comparative pathology of, 52 concomitant diseases of, 72 constitution in the causes of, 87 " critical," 74 Cullen's theory of, 96 . debilitating causes of, 91 dietetic regimen in the treatment of, 163 diminution of, in modern times, 84 etiology of, 81 excess in eating as a cause of, 87 exciting causes of, 91 experimental pathology of, 52 fermented liquor as a cause of, 88 Gout, gastric, 63, 64 varieties of, 64 Gout, general characteristics of, 40 general considerations in the treat- ment of, 156 historical pathology of, 82 hyoscyamus in the treatment of, 157 individual causes of, 86 indigestion as a cause of, 91 intellectual labor as a cause of, 91 intercurx-ent diseases of, 73, 74 iodide of potassium in the treatment of, 159 lead-poisoning as a cause of. 90 leeches in the treatment of, 159 lithium in the treatment of, 160, 161 liver in, 0d masked, 61, 62 morbific material in, 39 medical geography of, 85 metastasis in, 63 mineral waters in the treatment of, 161 misplaced. 62 misplaced treatment of, 163 moxa in the treatment of, 159 narcjtics in the treatment of, 159 nervous intiuence as cause of, 87 nervous system in, 67, 68 non-visceral, 70 opium in the treatment of 1 59 Gout, pathological blood conditions of, 41 physiology of, 81 Goub, pathology of, 95 permanence of the characteristics of, 84 potash salts in the treatment of, 160 primitive asthenic, 19 princip il forms of, 54 purgatives in the treatment of, 159 quinine in the treatment o:, 159 rational theory of, 95 respiratory apparatus in, 68 retrocedent, 40, 50. 62 return of attack of, 58 rheumatic, 101 Scudamore's theory of, 96 sex in the causes of, 87 soda-salts iu the treatment of, 160 temperament in the causes of, 87 Gout, tonics and stomachics in the treat- ment of, 163 topical remedies in the treatment of, 159 traumatic causes of, 91 treatment of, 156 treatment of a paroxysm of, 157 treatment of the constitutional con- dition of, 160 treatment of tophi in, 161 venereal excess as a cause of, 88 visceral, 50 definition of, 62 organic lesions of, 63 Gout, want of exercise as a cause of, 87 wet cold as a cause of, 91 Gout and rheumatism, 80 Gouty patients, uric acid in blood of, 40 Gravel and gout, 78 Gravel, biliary, 26 Gravel, uric acid, 75 and gout, 75 Gr ives, 16, 68 Great-toe, invasion of, in gout, 47 preferable attack of, in gout, 99 Gregory, 158 Griesinger, 67, 76, 132 Grisolle. 110 Gubler, 67 Guiibert, 64, 75, 141 Gurlt, 111 G;",terbock, 184 Guttman, 160 Hahn, 75 Halford, 150 Haller, 12 Hamernjk, 80 Hammond, 158 Hardy, 118 IHaney. 3. 97 lHasse, 111 ! Hattier, 108 I Haygarth, 102, 104, 150 Headache, rheumatismal, 67 Heart, auscultation of, in old age, 225 changes in, in old age, 223 fatty degeneration of, in gout, 66. 67 percussion of, in old age, 225 senile softening of, 227 state of. in gout, 6(5 urate of sod i in valves of, 51 varieties of, 226 Heart, fatty, 226 differential diagnosis of, 229 etiology of. 227 infiltration of, 227 prognosis of. 229 morbid anatomy of, 226, 227 physical signs of, 229 Quain's, 226 treatment of, 229. 230 Heart, fatty, and cardiac dilatation, dif- ferential diagnosis of, 229 Heat, animal, drugs that increase, 186 276 IXDEX. Heherden, 155 llecker, 84 Heller, 98 Hemorrhage, cerebral, 231 and alcoholic intoxication, differential diagnosis of, 234 and cerebral congestion, differential diagnosis of, 234 and embolism, differential diagnosis of, 234 and urasmia, differential diagnosis of, 234 etiology of, 232 morbid anatomy of, 231, 232 prognosis of, 234, 235 symptoms of, 232-234 treatment of, 335 Heredity in gont, 86 Herder, Herrmann, 128 Herschell, 6 Heynsius. 1 1 Hippocrates, 8, 0, 7, 20 Hirsoh, N5 Hiato-chemistry. 1 1 Histology, pathological, object of, 11 the doctrine in, 10 Holland, 41,70 Honrmnnn and Dechambre, 19, 2? Humors, uric acid in, 43 Hunter, 3 J, 75, 105 Huss. 38 11 vde- Salter, 08 Litm-chemistry, 5 I atro- mechanism. 5 Identity, doctrine of, 88, 89 Immunities, pathological, in old a^e, 24 Infarctions, visceral, 83 Juopexia, 12,' I. .filtration, cellular. 88 > Insanity, rheumatic. 132 Intestines, changes in, in old age. 241 Introduction. 1 Iritia in abartumlax gout, 71 rheumatic. 133 Jacks. 1215 .Tahn. 41 Jenkinson, 164 Joints in acute and subacute rheumatism, 109 attacked in gout, 48 changes in diseases independent of rheumatism. 112 deformity of. in nodular rheumatism, 139, 140 inflammation of. in gout. 40 Joints, nodosities of, 102 locomotor ataxy in, 133 J.rgensen. 175 Kidney." capillary embolism of, 128 Kidney, diseases of, in gout, 69 functional derangements of , in gout, 69 gouty. 79 granular, 52 gravel of the, 51 Kirkes. 127 Kreisig, 124 • Kussmaul, 111, 188 Laborde, 150 Laennec. 3, 9 Lancereaux, 113, 128 Landre-Beauvais, 19, 101, 102. 104 Lartigue's pills, 157 Laryngeal spasm and asthma, differential diagnosis of, 219 Laryngitis, chronic rheumatic, 132 Laaegae, 104 Latham, 129 Laugier. 71 Laville. liqueur de. 76 Laville's liquid, 1~7 Lawrence, 71 L7 Lungs, capacity of. in old age, 194 physiological changes in old age in the, 195 senile changes in the, 194 Lnaohka, Lynch. (54, 07 Lyon, Potton de, 04 Maelaehlan, 858 Haclagan, 858 Macleod, 110, 117. 150 Magondie, 10. 12, 190 Malcolm son. 149 Malgaigne, 106 Malono. 98 Mania, algidity in, 1S5 INDEX. 277 Marcet, 68 Marchal, 72, 73 Marey, 23, 86 Martel, 130 Meyer, H., 105 Mead, 157 Medicine, empirical and sc'entific, 2, 8 empirical, true character of, 4 histology in, 10 modern fundamental principles of, 3 physiology in, 13 result of science in, 14 revolution of, in Germany, 15, 16 scientific tendencies of, 15 the microscope in, 10 Membrane, synovial, changes in chronic rheumatism in, 106 in gout, 46 Mentegazza, 190 Mercury in the gouty, 74 Mesnet, 67, 132 Mettenheimer, 20 Michael, 30 Mischerlich, 160 Mitchell, 133 Morbus coxae senilis, 103, 143 Monneret, 30, 118, 119, 120, 157 Monti, 179 Moore. 59 Morehouse, 133 Morgagni, 3, 72, 78 Murchison, 24, 59, 74 Murexide test, 46 Muller, 3, 15 Murray, 78 Muscles in abarticular gout, 70 Musgrave, 90, 104, 153 Nasse, 121 Naturalism, 5 Necraemia, 188 Nephritis, albuminous, in gout, 69 gouty, 51 parenchymatous, 51, 52 Nerves in abarticular gout, 70 Nervous system in old age, 23 Neumann, 75 Nodi digitorum, 103 Nodosities of Heberden, 143, 146 pathology of, 146, 147 Nutrition in old age, 24 Obesity and gout, 77 Object of the course, 1, 17 QSdema, pulmonary, and asthma, differen- tial diagnosis of, 219 Oesophagus, implication of, in gout, 63 O'Ferral, 120 O' Henry, 43 Old age, atheroma of arteries in, 22 atrophy in, 21 brain in, 22 cerebral arterioles in, 22 Old age, external appearance in, 21 fatty degeneration in, 21 heart in, 21 kidneys in, 21 muscles in, 21 pigmentary degeneration in, 21 stature in, 21 textural changes in, 20 weight in, 21 works on, 18, 19, 20 Olliver, 110, 129 Opium in the gouty, 75 Ormerod, 129 Osteopsathyrose, arthritic, 104 Osteosarcoma, 145 Owen, 84 Paget, 22 Panum, 174 Paralysis, general, of the insane, 179 Parry, 64, 90 Pathology, anatomy and physiology in, 3, 5 experimental, 13 Hippocratic, 7 relation of physiology to, 12 senile history of, 18 Patissier, 68, 86 Percival, 145 Percussion, modification of, in old age, 203 Pericarditis, 124 acute, experimental, 13 and asthma, differential diagnosis of, 219 Pericardium, white spots on, 224, 225 Perry, 50 Perturbations, critical, 35 Petit, 43 Phlebitis, visceral, 31 Phlegmasia? in the gouty, 73 Phlegmon in the gouty, 73 Phthisis, algidity in, 185 Phthisis and gout, 77 ' Phthisis and senile bronchitis, differential diagnosis of, 213 Phthisis, gout, and scrofula, 79, 80 Phthisis pulmonalis, relation of rheuma- tism to, 132 Physiology a support to medicine, 5 experimental, 3, 10 modern purpose of, 12 of ancients, 6 pathology, 11 senile, 20 Pinel, 18 Piorry, 120 Plague, the, 28 Plate I., description of, 267 Plate II. , description of, 268 Plate III., description of, 269 Pleurisy and pneumonia, differential diag- nosis of, 207 Pleurisy, experimental, 13 gouty, 68 in the gouty, 74 278 INDEX. Pleurodynia, G8 gouty, 70 Pneumonia, algid, 192 bilious, 203 defervescence in, 34, 35 experimental, 13 gouty, 08 in the gouty, 74 Pneumonia, lobar, 27, 30 symptoms of, 32 temperature in, 32, 33, 34, Pneumonia, lobular, 32, 33, 34 Pneumonia and capillary bronchitis, dif- ferential diagnosis of, 200. 207 and pleurisy, differential diagnosis of, 207 differential diagnosis of, 200, 207 etiology of, 107 expectoration in, 198 face in, 201 gastric symptoms in, 202 headache in. 2u2 modes of termination of, 190 morbid anatomy of, 105, 107 pain in, 900 physical signs of. 198, 306, 206 prognosis of. '207. 208 respirations in. 200 symptoms of, 198 temperature in, l'JO treatment of, 208 uriue in, 202 Potton, L68 Price-Jones. 74 Process, thread, 42 Pruner-Bey, 140 Prurigo, arthritic. 188 Prostate, chronic enlargement of, 257 Prostate, hypertrophy of, 857 differential diagnosis of, 2G0, 881 etiology of. morbid anatomy of, 257, prognosis of. 201 symptoms of. 250, 200 treatment of, 861, S Prostate, hypertrophy of. and atony of the bladder, differential diagm 861 and stone in the bladder, differential diagnosis of, 861 and urethral stricture, differential diagnosis of. 201 prognosis of. 861 symptoms of, 250, 260 Prout, 66, 72, 78, 75. 70, 188 Prus, 10 Psoriasis in gout. 70 nomnlar, 138 Pulse, in old age. 88, 225, 000 frequency of, in old age, 100 Pyannia and animonaunia, differential diagnosis of, 204 Quain, 00, 07 Quo tele t. 81 Ramollissement, cerebral, 20G Ranke, 97 Ranvier, 105, 110, 112 Rayer, 24, 41, 51. 70. 72, 75, 198 Reaction, want of, in old age, 27, 28 Rectum, torpor of the, 250 Redfern, 105 Reil, 11 Remak, 133 Reouin, 4, 121, 140, 153 Respiration, character of, in old age, Respiration in old age Reynolds' elixir. 157 Rheumatism, age in the etiology of, 150 Rheumatism and gout comparison of etiology of, 154 Rheumatism, acute, chorea in, 188 duration of. 121 muscular paint in. pathological blood condition in, 121 seci 110 urine in, 190 vesical dipeaeee in. ral affections of Rheumatism, acute articular. 116 arthropathies in. 1 17 compared with gout. 120 Rheumatism, articular, etiology of, blennorrhagic. 152 chlorosis in. 158 :i between acu* i, 196 constitutional condition in, 118 117 imenorrhoae in, 153 endocarditis in. 121 ex . frequem gonorrheal. 152 I 108, 134 heredity in the etiology of. 149 historical patholog influence of poveity in, 151 its resemblanct medical g< -. 148, 140 pathological < is in, 124 sex in the i wet cold in the etiology of, 151 Rheumatism, chronic, abarticular diet in, 131 acute pneumonia in, 181 alkalies in the treatment ammoniated tincture of guaiacum in the treatment of. 105 anatomical eharae:< arsenic in the treatment of. 164 asthma in. 131 bloodletting in the treatment i : cerebral diseases in. . 138 emphysema in, 131 iodide of i>otassiuin in t!. of. 105 local remedial in t" ent of, 105 INDEX. 279 Rheumatism, medullary affections in, 133 mineral waters in the treatment of, 165 muscular pains in, 133 opium in the treatment of, 164 paralysis agitans in, 133 paraplegia in, 133 pericarditis in. 128, 130 pleurisy in 131 principal varieties of, 102 quinine in treatment of, 164 skin diseases in, 133 tincture of iron in the treatment of, 164 tremor in, 133 unity of, 104 varieties cf, 134 visceral affections in, 123 Rheumatism, chronic articular, 38 anatomical lesions of, 101 modifications in forms of, 108 treatment of, 164 Rheumatism, chronic progressive articu- lar, 102 symptomatology of, 134 varieties of, 102 Rheumatism, Heberden's, 103 visceral diseases in, 103 Rheumatism, nodular, 19, 38, 102 arthropathies in, 135 cardiac diseases in, 129 erysipelas in, 133 general symptoms of, 141 in old subjects, 139 in young subjects, 138 mode of production of deformities in, 140 two forms of, 141, 142 varieties of deformities in, 136, 437, 138 Rheumatism, partial chronic, 143 characteristics of, 144 Rheumatism, partial chronic articular, 103 Rheumatism, subacute, duration of, 121 endocarditis in, 128 eye diseases in. 133 pathological blood condition of, 121 sciatic neuralgia in, 133 trifacial neuralgia in, 133 traumatic causes of, 152 uterine functions in the etiology of, 153 Richardson, 99, 122, 173 Rindtleisch. 106 Ringer, 118 Robin, 22, 97 Rodier, 121 Rohrig, 188 Rokitansky, 15, 75 Rollet, 152 Romberg, 129, 135 Roseau, 19 Salpetriere Hospital, inhabitants of, 17 internal organization of, 17 Saturnismus in animals, 14 Scheele, 41, 95 Schelling, 15 Scherer, 97 Schlossberger, 22 Schmidtmann, 59, 74 Schnepf, 23 School, anatomical, 10 Viennese, 15 Schoenlein, 15 Schonlein, 72 Schottin, 120 Science, modern, 8 the universality of, 16 Scrofula, gout, and phthisis, 79, 80 Scudamore, 64, 68, 75, 79, 86 Secretions in old age, 23 See, 14 Seegen, 76 Septicaemia and ammongemia, differential diagnosis of, 264 Simon, 121, 185 Skin, diseases of, in abarticular gout, 70 Small-pox, hemorrhagic, 28 Smith, 101 Soda-urate, depositions of, 48 Soda, urate of, in joints, 40 Softening, acute cerebral symptoms of, 238 atrophic cerebral, 237 Softening, cerebral, 236 and cerebral tumors, differential diag- nosis of, 239 differential diagnosis, 239 etiology of, 237 morbid anatomy of, 236 prognosis of, 239 red, 236 treatment of, 239, 240 varieties of, 236 white, 237 yellow, 236 Softening, chronic cerebral, 237 symptoms of, 238 Speck, 98 Spinal cord, diseases of, in gout, 68 rise in temperature, in lesions of, 182 Spontaneity in the causes of gout, 86 Stahlism, 5 Stockhardt, 66 Stokes, 66, 174 Stomach, cancer of, 27 catarrh of, 241 changes in, in old age, 241 gout in, 64 gout in the, diagnosis of, 65 Stosch, 75 Stupor, gouty, 67 Sydenham, 78, 84, 104, 121, 173 Synocha, 31 Syphilis in the gouty, 74 Swammerdam, 30 Taine, 6 Temperature, extreme limits of, 160 febrile, in nervous diseases, 179 280 INDEX. Temperature, high febrile, in old age, 160 high, danger of, in old age, 170 in old age, 24 in pathological states of the aged, 169 low febrile, in old age, 109 mechanism of lowering the, 187-1£9 medium febrile, in old age, 169 normal, of old age, 16/ subnormal, 37 Tetanus, elevation of temperature in, 1 79 Thermometry, axillary, 37 4 in old age, 168 Thermometry, clinical, 30 importance of, in old age, 166 Thermometry, rectal, 37 in old age, 168 Thierfelder, 191 Thompson, 72 Thrombosis, experimental, 13 marasmic, 225 Todd, 51, 57, 59, 67-69, 119. 120, 122. 158, 155, 159 Tophi, 46, 48 clinical characteristics of, 59, 60 frequency of, 49 locality of, 49 seat of, 48 Trastour. 129, 140, 149, 150 Traube, 13. 30, 59 Trousseau. 57, (54. 67, 127, 153, 158 Tscheschichin, 188 Tuberculosis, pulmonary, 27 Tumors, cerebral, and cerebral softening, differential diagnosis of. 880 Turpentine, in the goaty, 75 Typhus, in the gouty, 74 Typhus fever, 28 Uraemia and apoplexy, differential diagno- sis of, 834 UlSBmia and cerebral hemorrhage, differ- ential diagnosis of, 234 Ubaldini, 43 Uhle, 97 Ulcer, atheromatosis, 224 Urate of lithia, 101 Uhl, 72 Urethra, stricture of, and hypertrophy of the prostate, differential diagnosis of, 201 Urethritis, gouty, 70 Uric acid, experimental production of, OS Olgmna in which, is formed. 07 sources of, 96 Uric acid diathesie, 55 dyspepsia in, 55 urine in, oo Urinary passages, diseases of, in gout, 69 Urine, in acute gout, 43 in chronic gout. 44 retention of, and paralysis of the blad- der, differential diagnosis of, 250 Valleix, 120 Van Swieten. 13, 67. 84, 122, 173 Veins, pulsation in, in old age, 885 Verge, y, 106 Vesalius, 3 Y. -sels, changes in, in old age, 223, 224 Vidal. 132. 1*9, 151 Vigla, 68 Vinmow, 18, 1''., 22 Vitalism. 8 Voisii, Von 15. rensprung, 167 Vulpian, 18, 22 Walah. 120 Wardrop. 71 i 65, 240 Webb. 140 Weber. 21. 185 Weber. O . 105, 106 ;. 18 120. 150 Wertphal, 170 Whvtt. 75 Wiilemin. I Williams 122. Wiutrich. 23 Wolff. 186 Wollaston. 41 Wunderlich, 80, 191 Xenophon. 151 Yellow fever. 88 Zalesky. 53, 97, experiments of, 53, 100 Z. is. 105 Ziemssen, 170 LIBRARY OF CONGRESS 022 216 236 1